Lights On Intake Interview Form

INTAKE INTERVIEW FORM
Client Information:
Name

First NameLast Name
Sex:
DOB:

MonthDayYear
Date
Diagnosis:
Parent/Caregiver Information:
Name

First NameLast 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:
List Medication Names, Dosages, Administration Notes/Schedule, and Duration (How long have they been taking this medication?)

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 Needs
Has the Individual Had A History of Sexual Abuse/Assault
Any racial variables that need to be considered for treatment?

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.

Should be Empty: