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INTAKE FORM
Parent’s Name (s):
Address:
Contact Email Address:
Phone Number:
Child’s Name:
Age:
DOB:
Siblings living in the home:
Siblings living outside the home:
Special diet/Allergies:
Current Medications:
Grade:
School:
Diagnosis:
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Date of Initial Diagnosis:
Does child receive Speech Therapy, Physical Therapy, Occupational Therapy,
Hippotherapy, etc.? If so, how often does child receive this therapy? :
Has child received ABA services previously? If so, when? :
Are there any current behavioral concerns and/or problem behaviors such as
elopement, noncompliance, aggression, tantrums, throwing objects, self harming
behaviors, etc.? If so, please estimate the number of times per day each behavior occurs.
Please discuss:
Describe current eating and drinking patterns. Please indicate if child can feed self, what
texture/types of foods he/she can eat. Also list if child is using sippy cups, bottles, or
open mouth cups:
Describe sleeping patterns, sleeping schedule, bedtime, sleep consistently through night,
etc:
Describe any current toileting issues, attempted toilet training instances, is child
currently wearing diapers/pull ups/underwear, etc:
Please complete the following statement:
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I am seeking ABA services for my child to receive assistance in the following areas:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
Please list the four most critical skill deficits that you want your child to get help with.
Number the items 1-4 with 1 being what is most important to you. For example: 1)
Language, 2) Sibling Interaction, 3) Following Directions, & 4) Bedtime Routine.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please describe your child’s current functioning level in the following areas:
VOCAL IMITATION Is skill currently present? Is skill emerging, partially
mastered, or fully
mastered?
Sounds
Words
Simple Phrases
Songs
Complex Phrases
Number Sequences
SPONTANEOUS Is skill currently present? Is skill emerging, partially
VOCALIZATIONS mastered, or fully
mastered?
Spontaneous vocals
Spontaneous imitation of
words, or sounds
Spontaneous requesting
Spontaneous labeling
PLAY & LESIURE SKILLS Is skill currently present? Is skill emerging, partially
mastered, or fully
mastered?
Explores toys in
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environment
Plays with toys as they are
designed
Verbalizes while playing
Plays interactively with
peers
Allows peers to be close
during play
Imitates peers during play
Pretend play
Has appropriate indoor
play skills
Has appropriate outdoor
play skills
SOCIAL INTERACTION Is skill currently present? Is skill emerging, partially
mastered, or fully
mastered?
Tolerates touch from peers
Makes eye contact with
peers
Respond to peers
Talks to peers
Imitates peers
Takes offered item from a
peer
Willingly shares items with
peers
Physically approaches and
engages peers
Will request a peer to do an
activity (verbally or
nonverbally)
Asks for information
Labels items for others
Maintains attention of
others
DRESSING Is skill currently present? Is skill emerging, partially
mastered, or fully
mastered?
Can dress self with help
Can dress self with no help
Can adjust clothing as
needed
Can label clothing (verbally
or nonverbally)
EATING Is skill currently present? Is skill emerging, partially
mastered, or fully
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mastered?
Can feed self with help
Can feed self with no help
Can keep area clean while
eating
Requests meals/snacks
(verbally or nonverbally)
TOILETING Is skill currently present? Is skill emerging, partially
mastered, or fully
mastered?
Is currently toilet trained,
with help
Is currently toilet trained,
with no help
Can remain dry throughout
the day
Will request the bathroom
(verbally or nonverbally)
Will urinate in toilet
Will defecate in toilet
Use this space to record any additional comments or questions you have:
