INTAKE INTERVIEW FORM
Primary Care Physician:
Other Treating Professionals (Past and Present) - Include any Counseling, Occupational Therapy, ABA, Speech, Educational Services, Etc. Provider Name Company
Dates in Treatment
Please enter a valid phone number.
List Medication Names, Dosages, Administration Notes/Schedule, and Duration (How long have they been taking this medication?)
Any history of seizures?
Medication side effects?
Caregivers, Names and Relationships
Siblings, Names and Ages
Any legal issues?
Any spiritual variables?
Any cultural variables?
Paternal Medical History
Paternal Behavioral-Health History
Maternal Medical History
Maternal Behavioral-Health History
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:
Who referred you to Lights on ABA Services (Name, agency, phone #)?
Current Parental Concerns & Problems Related to Diagnosis
(How does your child communicate his wants and needs to you?)
(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: