Child Information

Child First Name

Child Last Name

Childs Date of Birth

Gender

Insurance Information

Insurance Type

Policy #

Front of insurance Card

Back of insurance card

Parent / Guardian Information

First Name

Last Name

Relationship to Child

Best Contact Number

Email *

Address

City

Zip Code

Parent / Guardian 2

First Name

Last Name

Relationship to Child

Phone Number

Email Address

Address (if different than above)

Child Lives with:

Additional Familial Information:

Siblings: (please indicate name, age, and relationship)

Are translation services needed? What language?

Are there any specific religious and/or cultural 1 considerations staff should be aware of?

Medical Information

Pregnancy/Childbirth

Date of Diagnosis:

Diagnosis: (List all that apply)

Age at Diagnosis:

Allergies

Symptoms at time of Diagnosis and/or Initial Concerns which led to Diagnosis:

Current Medications and Dosage:

Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Additional Medical Diagnosis and/or Concerns:

Diagnosis provided by: (include credentials)

Service Delivery

ABA Therapy (Please list frequency and duration):

What experience have you had with ABA treatment? (Assessing caregivers understanding of treatment):

Speech and Language Therapy (Please list frequency and duration):

Occupational Therapy (Please list frequency and duration):

Other Therapies

Physical Therapy (Please list frequency and duration):

Strength & Areas of Concern

Child’s Strengths:

Please list your current concerns in the following areas:

Communication:

How does your child communicate (words/gestures/signs)

Does the child respond to receptive communication (when you talk to them, following directions, etc.)

Socialization:

How does your child play with other children?

Does your child communicate with other children?

Does the child display socially inappropriate behaviors?

Daily Living Skills:

Child is able to tolerate hygiene activities (showering, washing hands, tooth brushing etc.)

Challenging Behaviors:

Common antecedents (What happens before the behavior?)

Common consequences (what happens after the behavior?)

Average frequency/Duration

Intensity of Behaviors

Toileting/Feeding/Sleep:

Child is able to complete age-appropriate living skills independently (dressing, washing hands, etc.)

Is the child toilet trained? (age 2-3 is typical)

Yes

Likes and Dislikes

Please list your child likes and dislikes

Dislikes

Likes

Goals / Policies and Procedures

What skills would you like your child to develop within the next 6 months?

What are you hoping to achieve through ABA services? (Potential priorities and terminal goals)

Is there any other information you would like us to be aware of or consider prior to beginning services?

Parent training is recommended 1 per week for new families and a minimum of at least 1 hour a month is required.

Parent training is important for generalization of skills/ required by insurance.

As a parent, what would you like to learn from our team during parent training?

When is the best time to schedule parent training?

What is your availability for services?

Other services in the school or community that the child may also benefit from.

Any Additional Information