Adult Day Program Application

New Learner Application

Please provide your information below and a representative from Behavioral Learning will reach out soon with next steps.
Learner/Client Name

First Name Last Name
Date of Birth

Month Day Year
Preferred Pronoun
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Learner/Client Phone Number

Area Code Phone Number
Learner/Client Email
example@example.com
Emergency/Guardian Name

First Name Last Name
Emergency/Guardian Number

Area Code Phone Number
Emergency/Guardian Email
example@example.com
Do you authorize communication via text?

Over the past 6-months, how often do you, or your learner, struggle with or experienced any of the following challenges?

	Not at all-0	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
10. Panic attacks, or feeling so paralyzed you cannot move
11. Avoiding responsibilities
12. Use substances (e.g., alcohol, marijuana, etc.), either to pass time or to better manage your symptoms

How difficult have the above experiences made it for you, or your learner, to do your/their work, take care of things at home, or get along with other people?

	1	2	3	4	5

1 is Not difficult, 5 is Very difficult

What are you, or your learner's, current coping strategies or activities that you/they have done to feel better or deal with the above-mentioned challenges?
What do you hope to achieve as a part of this program?
Have you/your learner participated in counseling in the past?
If YES, when?
Have you/your learner participated in ABA in the past?
If YES, when?
Are you/your learner taking psychotropic medications?
If YES, write the name(s) below
Name of Prescribing Physician
Have you/your learner ever been admitted to a hospital/facility for psychiatric care?
If YES, include Month/Year

Now create your own JotForm - It's free! Create your own JotForm

New Learner Application

Strengths & Challenges