INTAKE INTERVIEW FORM
Client Information:
Name
First Name
Last Name
Sex:
DOB:
-
Month
-
Day
Year
Date
Diagnosis:
Parent/Caregiver Information:
Name
First Name
Last Name
Relationship:
Phone:
E Mail:
example@example.com
Address:
Insurance Information:
Provider:
Phone Number:
Policy/Member Number:
Phone Number:
Primary Care Physician:
Phone:
Other Treating Professionals (Past and Present) - Include any Counseling, Occupational Therapy, ABA, Speech, Educational Services, Etc. Provider Name Company
Provider Name
Company
Service
Phone
Dates in Treatment
1.
2.
3.
4.
5.
School Information:
School:
Grade:
Teacher:
Contact:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Supplemental Questionnaire:
Medical
Answer
Any history of seizures?
Any allergies?
Medication side effects?
Vision Impairments?
Hearing Impairments?
Motor Impairments?
Nutritional Intake?
Hospitalizations?
Notes/Other
Family, History
Answer
Caregivers, Names and Relationships
Siblings, Names and Ages
Any legal issues?
Any spiritual variables?
Any cultural variables?
Notes/Other?
Paternal Medical History
Paternal Behavioral-Health History
Maternal Medical History
Maternal Behavioral-Health History
Primary Language
Transportation
Current Concerns, Supplemental Questionnaire Continued:
Answer
Who referred you to Lights on ABA Services (Name, agency, phone #)?
Current Parental Concerns & Problems Related to Diagnosis
Favorite Activities/Preferences
Communication
(How does your child communicate his wants and needs to you?)
Instruction Following
(What types of instructions does he/she have difficulties following? What instructions does he/she successfully follow?)
Engagement in Activities
(What are some activities that he/she enjoys to engage in, does not enjoy engaging in?)
Are you willing to participate in frequent (weekly, bi-weekly) family training? (If yes, how many family members would be attending?)
Is the client currently or has a history of alcohol or drug use/abuse?
For clients 12 years and above.
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