Client Intake Questionnaire

Confidential. The Client Intake Questionnaire is the first clinical document completed for every new child or adolescent referred to [Company]. A parent, legal guardian, or other primary caregiver completes it at, or shortly before, the initial appointment. Its purpose is to give the clinical team a structured picture of the child before any assessment session takes place, and to gather the information needed to discuss the case with the family’s insurance company and obtain authorization for services.

The questionnaire captures family and contact information, therapy preferences and availability, emergency contacts, medical and diagnostic history, current medications, birth and developmental history, a verbal behavior language screening (manding, tacting, echoic, intraverbal, receptive, imitation, and visual skills), a brief behavior baseline, and a comprehensive checklist of current behavioral concerns. All information is treated as strictly confidential, stored in the recipient’s clinical file, and shared only with personnel directly involved in the child’s care or with payors as required to authorize services.

The Client Intake Questionnaire form on the right captures every field. Families are welcome to attach additional reports, evaluations, IEPs, or any other records they believe will help the clinical team understand the child’s needs. The completed questionnaire is filed in the recipient’s clinical record.