New Client Intake Form
This form is to be completed by the Parent/Guardian of the client of Behavior Works FL prior to the initial consultation visit.
Client Information
Client Full Name
Client Date of birth
Street Address
Social Security #
Insurance Information
Name Of Insurance Comapny:
Name of Policy Holder:
Social Security # Of Policy Holder
DOB of Policy Holder
Insurance Address:
Insurance Phone Number
Member ID
Group ID
Photo of Insurance Card (Front)
Photo of Inusrance Card (Back)
Parent/Guardian Information
Parent/Guardian (1) Name:
Parent/Guardian (1) Email:
Parent/Guardian (1) Cell Phone#:
Parent/Guardian (1) Home Phone:
Parent/Guardian (2) Name:
Parent/Guardian (2) Email:
Parent/Guardian (2) Cell Phone:
Parent/Guardian (2) Home Phone:
Primary Street Address
Medical Information
Name of Primary Care Physician
Primary Care Physician Phone Number
Primary Care Physician Address:
Diagnosis:
Date of Diagnosis:
Name of Diagnosing Physician:
Medical Treatment History:
Are there any other medical conditions the client has which may impact the treatment of ASD, or may require staff to respond different to symptoms? Ifyes, please explain.
Medical Information (cont.)
History of Infectious Disease:
Known Allergies:
Has the client ever been hospitalized for behavioral concerns? If yes, please briefly explain.
Yes
No
Family Medical and Behavioral Health History:
Please describe birth history including any complications below: (delivery, complications, etc.)
Birth Weight:
Weeks Gestation:
How do you rate your child’s overall health?
Excellent
Very Good
Good
Not Very Good
Poor
Education Information
Name of School District:
Classroom Type
Grade
School Phone #:
School Address:
Does the client receive an extended school year (ESY)?
Yes
No
If yes, what are the dates of ESY and what type (classroom,social, etc.)
Does the client receive special education services at school?
Yes
No
If yes, what services do they receive at school?
Medical Questionnaire
(Please check all that apply)
Muscle & Bone:
Painful
Stiffness
Muscle Weakness
Back Pain
None Of The Above
No Comment
Muscle & Bone Comments / Other:
Nervous System & Brain
Weakness / Clumsiness
Tingling / Burning
Delayed Development
Numbness
Speech Delay
None of the above
No Comment
Nervous System & Brain Comments / Other
Heart
Chest Pain
Ankle Swelling
Heart Palpitations
None of the above
No Comment
Heart Comments / Other:
Urinary Tract Info
History of frequent bladder infections
Frequent urination
Trouble starting urine
Loss of urine with cough or sneeze
None of the above
No comment
Urinary Tract Comments / Other
Blood & Metabolism
Easy bleeding / bruising
Swollen lymph nodes
History of thyroid disease
History of diabetes
None of the above
No comment
Blood & Metabolism Comments / Other:
Medical Questionnaire Cont.
Reproduction:
Sexually active
Pregnant or planning or pregnancy
Breast feeding
History of yeast infection
Non of the above
No comment
Reproduction comments / other:
Psychological & Behavioral
Anxiety
Depression
Suicidal
Autism
Bi-polar Disorder
ADHD
Sleeping Issues
Feeding/ eating issues
None of the above
No comment
Psychological & Behavioral comments / other
Please list/describe feeding/eating issues:
Please list/describe sleeping issues:
Are immunizations up to date?
Why are immunizations not up to date? (If they are up to date write n/a):
Date of last flu vaccine:
Medications
Medication 1
Medication 1 Strength (mg/puffs)
Medication 1 Frequency
Medication 1 Date Started
Medication 2
Medication 2 Strength (mg/puffs)
Medication 2 Frequency
Medication 2 Date Started
Medication 3
Medication 3 Strength (mg/puffs)
Medication 3 Frequency
Medication 3 Date Started
Medication 4
Medication 4 Strength (mg/puffs)
Medication 4 Frequency
Medication 4 Date Started
Medication 5
Medication 5 Strength (mg/puffs)
Medication 5 Frequency
Medication 5 Date Started
Medication 6
Medication 6 Strength (mg/puffs)
Medication 6 Frequency
Medication 6 Date Started
Strength 1
Strength 2
Strength 3
Strength 4
Area of Need 1
Area of Need 2
Area of Need 3
Area of Need 4
Some activities I like to do with my child are:
I wish I could enjoy the following activities with my child but they are not possible at the moment:
Have you observed overall improvement in your child’s behavior and ability to learn new skills? Please explain:
In what areas/skills would you like parent training and support?
Is there anything else that you would like to discuss? Please write any questions or concerns that you have regarding your child and ABA services.
Please describe any problem behaviors, interfering behaviors of concern, or other reasons why you are seeking treatment:
Please describe the expectations/goals that you have for the client while engaging in behavioral programming:
Psychological conditions affecting the client’s status (other than ASD):
Does the client engage in any behaviors that may pose a risk to themselves or others? (Including but not limited to behaviors such as biting, scratching, head-banging, tantrums)
Please list any other information that may be helpful while assessing and/or conducting therapy with the client:
Tantrums
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Aggression
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Verbal Threats Towards Self
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Verbal Threats Toward Others
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Sure Stereotypy (repetitive movements, staring at objects for long periods of time, hand flapping, spinningself or objects):
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Sure Perseveration:
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Sure Rigidity:
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Ritualistic:
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Obsessive
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Injurious (SIB):
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Elopement (bolting, running away):
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Flopping or dropping to the ground
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Hypersensitivity
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Hyposensitivity
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Distractibility
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Hyperactivity
Yes
No
Not Sure
No elements found. Consider changing the search query.
List is empty.
Behavioral Provider Name:
Behavioral Provider Contact:
Dates of Services:
Please state the therapy outcomes:
Speech and Language Pathology Provider Name:
Speech and language Pathology Provider Contact:
Dates of Speech and Language Pathology Services:
Please state the speech therapy outcomes:
Occupational Therapy Provider Name:
Occupational Therapy Provider Contact:
Dates of Occupational Therapy Services:
Please state the occupational therapy outcomes:
Other Therapy Provider Name:
Other Therapy Provider Contact:
Dates of Other Therapy Services:
Please state other therapy outcomes:
Availability of Services (please input start and end times)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday