Intake Document

Name of Child/Adolescent:

Nickname:

Child’s Date of Birth:

Age:

Parent/Guardian 1 Name:

Phone:

Email:

Parent/Guardian 2 Name:

Phone:

Email:

Emergency Contact (Name, Phone, Relationship):

Insurance Provider:

Insurance Number:

Cardholder Name:

Physician Name & Contact Information:

Court/legal system involvement and/or Child protective services involvement: YesNo

Neurological/Developmental Disorders: Autism Spectrum DisordersIntellectual DisabilityLearning DisabilitiesADHD/Attention ProblemsSeizure DisordersCerebral Palsy

Mental Health Disorders: DepressionAnxietyBipolar DisorderPsychosis/SchizophreniaPTSDBehavioral ProblemsEating DisordersSubstance Abuse/Dependence

Other Health/Medical Conditions: DiabetesHeart DiseaseEpilepsyMigrainesAsthmaVision/Hearing Impairments

Has your child received any psychological evaluations? YesNo

Has your child received previous behavioral health services (e.g., ABA, psychotherapy, psychiatric services)? YesNo

Rolled Over:

Sat Unsupported:

Walked Unassisted:

First Word:

Behavioral Concerns (e.g., Isolation, Temper Issues, Sleeping Problems):

How would you rate your child’s current physical health? PoorUnsatisfactorySatisfactoryGoodVery Good

Medical Conditions/Surgeries:

Medications:

Any issues with sleeping or eating? YesNo

If yes, explain:

Current Grade:

Teacher Name:

School Name & Address:

Has your child received special education services? YesNo

If yes, check all that apply: IEP504 PlanPhysical TherapySpeech TherapyOther

What are your child’s favorite activities/items?

What would your child like to do more often?

Social/Communication Skills: How does your child communicate their needs?

Behavior:

What does it look like?

Frequency/Intensity:

How do you respond?

Behavior:

What does it look like?

Frequency/Intensity:

How do you respond?