CLIENT INTAKE FORM APPLIED BEHAVIOR ANALYSIS (ABA)

CLIENT INTAKE FORM APPLIED BEHAVIOR ANALYSIS (ABA)
Identifying Information
Client’s Name*
Middle
Last*
Preferred
DOB
Race
Marital Status
Client ID #
Record #
Referred by
Medicaid #
If applicable, any additional third party coverageOther
Sponsor's Social Security #
Address
PROVISIONAL/ADMITTING DIAGNOSIS
Current Diagnoses
Date of Diagnoses

MonthDayYear
Date
Age of Diagnoses
Diagnosed by
MEDICAL INFORMATION
Physical/Medical Conditions: N/A or mark all that applies; include date of diagnosis, (past and current) diagnostician if known, (past and current) treatment, and responses to treatment.

No Known Allergies:Allergies: food, drug, environmental, manmade
Adverse reactions to allergen:
Serious illnesses (e.g., seizures, heart disease, respiratory problems, diabetes, gastrointestinal)Infectious diseases (e.g., chickenpox, measles, pneumonia, tuberculosis, other)Visits health specialists e.g., neurologist, cardiologist, endocrinologist, ear/nose/throat, dermatologistHospital stays and/or surgeriesVision or hearing problemsMobility problemsSpecial diet e.g., gluten, casein-free, mechanical alteredOther medical issues (e.g., migraines
Serious illnesses (e.g., seizures, heart disease, respiratory problems, diabetes, gastrointestinal):
Infectious diseases (e.g., chickenpox, measles, pneumonia, tuberculosis, other):
Visits health specialists e.g., neurologist, cardiologist, endocrinologist, ear/nose/throat, dermatologist:
Hospital stays and/or surgeries:
Vision or hearing problems:
Other medical issues (e.g., migraines):
Mobility problems:
Special diet e.g., gluten, casein-free, mechanical altered:
Immunization Record:

YesNo
If no, please explain
Do you have a Primary Care Physician?

YesNo
Name of Primary Care Physician
Address
Phone #
Note Golden Rule ABA, LLC does not assist in administering any medications over the counter or prescription.*

Takes medications, vitamins, or herbal supplements

Note Golden Rule ABA, LLC does not assist in administering any medications over the counter or prescription.

	Current Medications	Instructions	Prescribed For

Previous medications:
NOTE: Add any additional current or previous medications to the “Additional information” sheet on Page 10.
MENTAL HEALTH INFORMATION
Neurodevelopmental Disorders:

N/A or mark all that applies; include date of diagnosis, (past and current) diagnostician if known, (past and current) treatment, and responses to treatment.Intellectual Disability (e.g., Mild, Moderate, Severe, Profound, Unspecified)Communication Disorders (e.g., Language Disorder, Social Communication Disorder, Speech Sound Disorder)Autism Spectrum Disorder – Severity Level: ( ) 1 ( ) 2 ( ) 3Attention – Deficit/Hyperactivity DisorderLearning DisorderMotor Disorders (e.g., Developmental Coordination Disorder, Stereotypic Movement Disorder, Tourette’s Disorder, Tic Disorders)
Mental Health/Psychiatric Conditions

N/A or mark all that applies; include date of diagnosis, (past and current) diagnostician if known, (past and current) treatment, and responses to treatment.Schizophrenia Spectrum/Other Psychotic Disorders (e.g., Schizophrenias, Schizoaffective Disorder, Delusional Disorder)Bipolar DisorderDepressive Disorders (e.g., Major Depressive Disorder, Persistent Depressive Disorder)Anxiety DisordersTrauma/Stress-Related Disorders (e.g., Acute Stress Disorder, Post traumatic Stress Disorder, Adjustment Disorders)Feeding and Eating Disorders (e.g., Pica, Rumination Disorder, Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)Disruptive and Impulse-Control Disorders (e.g., Oppositional Defiant Disorder, Intermittent Explosive Disorder, Conduct Disorder)Substance-Related and Addictive DisordersNeurocognitive Disorders (e.g., Traumatic Brain Injury, Delirium)Other Mental Health Conditions e.g., Dissociative Disorders, Sexual Dysfunctions, Gender DysphoriPsychiatric hospitalization/Crisis stabilizationSuicidal ideation, or historyHomicidal ideation, or history
BEHAVIORAL HEALTH TREATMENT INFORMATION
Do you presently have another behavioral health treatment provider?

YesNo
Name of Provider
Address
What type of treatment(s) are you receiving?
Start of treatment
Dosage of treatment
Early Intervention
Service provider name
Contact information
Dates of treatment

MonthDayYear
Date
Interventions used
Responses to treatment
Special Education
Service provider name
Contact information
Dates of treatment

MonthDayYear
Date
Interventions used
Responses to treatment
Medicaid Waiver Services
Service provider name
Contact information
Dates of treatment

MonthDayYear
Date
Interventions used
Responses to treatment
ABA Program
Service provider name
Contact information
Dates of treatment

MonthDayYear
Date
Interventions used
Responses to treatment
Cognitive Behavioral Therapy (CBT)
Service provider name
Contact information
Dates of treatment

MonthDayYear
Date
Interventions used
Responses to treatment
Other
Service provider name
Contact information
Dates of treatment

MonthDayYear
Date
Interventions used
Responses to treatment
Guardianship:

Own GuardianMinor/CustodianGeneral GuardianLimited GuardianPower of AttorneyGuardian(s) of the Person
Name of Guardian
Phone number of guardian
Email of guardian
Qualification Date

MonthDayYear
Date
Successor Guardian, if known
Advance Directive (Living Will):

YesNo
SOCIAL/FAMILY INFORMATION
Mother
Phone number of mother (If applicable)
Email of mother (If applicable)
DOB
Occupation
Father
Phone number of father (If applicable)
Email of father (If applicable)
DOB
Occupation

Siblings:

	Name	DOB:	Contact information, if applicable

Name
Relationship to the Client
Family Values, Cultural/Spiritual/Religious Practices:
Community Resources (Indicate any community resource that your family or child is currently utilizing):
Support Groups
Social Services
Recreational
Social Based
Others
Is there a history of medical treatment in your family?

YesNo
If yes, please explain
Is there a history of mental health treatment in your family?

YesNo
If yes, please explain
Is there past exposure trauma?

YesNo
Is there a history of substance use (e.g., alcohol, tobacco, or other drugs) in your family?

YesNo
Is there a history of legal issues (e.g., probation, guardianship) in your family?

YesNo
DEVELOPMENTAL INFORMATION
Received prenatal care during pregnancy?

YesNo
Did biological mother experience complications (e.g., gestational diabetes, premature labor) during pregnancy or were there any unusual changes in baby’s activity level during pregnancy?

YesNo
Prenatal exposure to alcohol, tobacco, or other drugs?

YesNo
If yes, please explain
Was he/she born full-term?

YesNo
If no, indicate how premature or overdue
Birth Weight
Describe any complications during or after delivery
Education Status:

Graduate/ProfessionalBaccalaureate DegreeSome CollegeAssociate Degree, Technical DegreeHigh School GraduateGed1-3 years of High SchoolComplete up to Ninth GradeCompleted less than Ninth Grade
Currently enrolled - Grade
School
Teacher
Educational Classification
Is or was he/she placed in a special education class?

YesNo
If yes, please explain
Does or did teacher report any concerns regarding academic or behavioral challenges?

YesNo
If yes, please explain
Does or did teacher report any social challenges?

YesNo
If yes, please explain
Does or did he/she receive special help (tutoring, extra time to complete work)?

YesNo
If yes, please explain
Does or did he/she receive discipline for serious behavior problems at school?

YesNo
If yes, please explain
EMPLOYMENT
N/A
Currently employed?

YesNo
Job Title
Employer
Previous Employment
RECREATION
Going to the parkBoard GamesMusic (listening)YMCAVideo GamesMusic (playing)SwimmingSensory ActivitiesGrocery/household shoppingDancingArts & CraftsDining OutBowlingBook/Magazines/NewspapersMovie TheaterSkatingTV/MoviesChurch/Religious ActivitiesSocial ClubsAttend Sports EventsParticipate in SportsGoing to the parkPuzzlesHobbies:Other
Are there any special considerations regarding integration into the community, including transportation?
NEEDS
Maintain Health and Safety.Supervision & engaging participation with eating, bathing, dressing, personal hygiene and other activities of daily living.Needs assistance with acquisition, retention, or improvement in skills related to activities of daily living.Training and/or support in interpersonal skills and the development and maintenance of personal relationships.Build skills in self-advocacy.Build natural supports.Community networking such as participation in adult education, volunteering, etc.Community integration such as shopping, recreation, personal banking, grocery shopping, & other community.Periodic support and relief to the primary caregiver(s).Other
STRENGTHS
There is no evidence of physical or medical problems or only mild/well-managed physical or medical programs.He/she has and enjoys positive recreational activities on an ongoing basis.He/she desires active treatment/habilitation and is willing to remain involved in his/her treatment.He/she has significant family strengths: a family with love and mutual respect for each other. Family member are central in each other’s lives.He/she has significant interpersonal strengths. The individual is seen as well-liked by others and has is able to form and maintain positive relationship with others.He/she is in school or a pre-voc/vocational training or enrichment program and is involved with an educational plan or work environment that appears to meet expectations.He/she has ties with his/her community.He/she has significant natural supports who contribute to helping support his/her health and well-being.He/she has caregivers who are consistently involved in the planning of services and advocates on behalf of the client.He/she has a clear and consistent cultural identity & is connected to others who share his/her cultural identity.Other
ADDITIONAL INFORMATION
Completed by
Date

MonthDayYear
Date
Reviewed by (Parent/guardian name)
Sponsor/Parent ID number (social security number)
Best contact email address
Behavioral Services Manager/Clinician, License/Certification
Date

MonthDayYear
Date
Should be Empty:

CLIENT INTAKE FORM APPLIED BEHAVIOR ANALYSIS (ABA)

Identifying Information

PROVISIONAL/ADMITTING DIAGNOSIS

MEDICAL INFORMATION

MENTAL HEALTH INFORMATION

BEHAVIORAL HEALTH TREATMENT INFORMATION

SOCIAL/FAMILY INFORMATION

DEVELOPMENTAL INFORMATION

EMPLOYMENT

RECREATION

NEEDS

STRENGTHS