Appendix 3

Client Intake Questionnaire

Active clinic: [Company]

Confidential intake questionnaire completed by a parent or guardian for every new child or adolescent. Captures demographics, family contacts, medical and developmental history, language and behavior baseline, and current behavioral concerns so the file is ready for assessment and insurance authorization. Feel free to attach additional reports that you think may be helpful in getting to know your child.

Today's date *

General Information

Name of person completing this form *

Relationship to child or adolescent *

Legal name of child or adolescent *

Date of birth *

Age

Gender

Female
Male

Language(s) spoken at home

Guardianship status

Full custody
Shared custody
Court appointed
Other

If other, please specify

How did you hear about us?

Mother

Mother's name

Address

Phone number

Father

Father's name

Address

Phone number

Sibling 1

Name

Age

Gender

Female
Male

Sibling 2

Name

Age

Gender

Female
Male

Sibling 3

Name

Age

Gender

Female
Male

Sibling 4

Name

Age

Gender

Female
Male

Sibling 5

Name

Age

Gender

Female
Male

Preferred Therapy Location

The final location of services will be determined during the assessment and will be decided based on medical necessity.

If other, school, or community, specify address

Weekly Availability

Indicate which days and time blocks your child is generally available for therapy.

Emergency Contact 1

In the event of a medical emergency, we will contact the person(s) you have indicated below on your behalf.

Name

Relationship to child

Phone number

Emergency Contact 2

Name

Relationship to child

Phone number

Emergency Contact 3

Name

Relationship to child

Phone number

Medical Information

Primary physician

Phone number

Diagnosis 1

Diagnosis

Diagnosis code

Diagnosing physician

Date diagnosed

Diagnosis 2

Diagnosis

Diagnosis code

Diagnosing physician

Date diagnosed

Diagnosis 3

Diagnosis

Diagnosis code

Diagnosing physician

Date diagnosed

Medical Conditions

Details (vision, hearing, seizures, surgeries, allergies, other)

Education and Services

Does your child currently go to school?

Grade

Has your child participated in an IEP (Individualized Education Program)?

Does your child receive any therapies or special services?

Therapy or Service 1

Company name

Type (ST, OT, HHA)

Mon

Time

Tue

Time

Wed

Time

Thu

Time

Fri

Time

Sat

Time

Therapy or Service 2

Company name

Type (ST, OT, HHA)

Mon

Time

Tue

Time

Wed

Time

Thu

Time

Fri

Time

Sat

Time

Therapy or Service 3

Company name

Type (ST, OT, HHA)

Mon

Time

Tue

Time

Wed

Time

Thu

Time

Fri

Time

Sat

Time

Current Medication

Is your child currently on medication?

Medication 1

Name

Dosage

Frequency or mode

Reason

Medication 2

Name

Dosage

Frequency or mode

Reason

Medication 3

Name

Dosage

Frequency or mode

Reason

Medication 4

Name

Dosage

Frequency or mode

Reason

Medication 5

Name

Dosage

Frequency or mode

Reason

Birth and Developmental History

Type of Birth

Induced
Vaginal
Caesarian

Term

Full
Premature

Length

Complications or concerns with pregnancy or delivery

Are motor and communication milestones following typical developmental patterns?

If no, please explain

Please indicate any of the following concerns

Feeding
Sleeping
Toileting

Please describe

Language Screening

Does your child use any words?

Does your child exhibit any of the following behaviors when trying to communicate?

Crying
Pushing or pulling
Gestures or pointing

Which of the following does your child use to communicate?

Single words
2 to 3 word phrases
Sentences

Does your child use any of the following methods to communicate?

Sign language
Pictures
Other

If other, specify

If no words, does your child babble?

If yes, list the sounds you have heard

About Your Child's Skills

These questions help us get to know your child. There are no right or wrong answers. Answer based on what you see at home and out in the world.

How does your child let you know what they want? (For example: pointing, taking your hand, saying a word, leading you to it)

Can your child name things they see in books, pictures, or around the house?

Yes
Sometimes
Not yet

Can your child repeat words after you?

Yes
Sometimes
Not yet

Does your child say things they have memorized from movies, shows, or past conversations?

Can your child finish familiar songs or fill in the blank in everyday phrases? (For example: "Twinkle, twinkle, little ___" or "You sleep in a ___")

Yes
Sometimes
Not yet

When you call your child's name, do they respond?

Almost always
Usually
Sometimes
Almost never

When you ask your child to do something simple, do they follow the instruction?

Almost always
Usually
Sometimes
Almost never

Does your child copy what you do? (For example: clapping hands, waving, rolling a car)

Yes
Sometimes
Not yet

Can your child match the same picture or object to another, or finish puzzles that are right for their age?

Yes
Sometimes
Not yet
Unsure

Can your child sit with an adult and do a simple activity together for a few minutes? (For example: coloring, stacking blocks)

Yes
Sometimes
Not yet

Anything else you would like to share about how your child plays, learns, or communicates?

Current Behavioral Concerns

Please indicate if your child or adolescent engages in any of the following behaviors. Check all that apply.

Insurance Information

Insurance name (e.g., Medicaid)

Primary insurance provider

Member / ID number

Group number

Policy subscriber (full name)

Documents Provided at Intake

Parent Intake Document Checklist for ABA Services. Please provide copies of the following documents, if available. Check each item as you provide it.

Identification & Insurance

Parent/Guardian Photo ID
Insurance Card(s) (Front and Back)
Insurance or Funding Card (If Applicable)

Medical & Referral Documents

Physician Referral / Prescription for ABA Services
Psychological Evaluation
Medical Records Relevant to Treatment

Educational Records

Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
504 Plan (if applicable)
School Evaluation Reports
Behavior Intervention Plan (BIP)
School Progress Reports or Report Cards

Previous Therapy and Service Records

Previous ABA Assessment(s)
Previous ABA Treatment Plan(s)
Previous Behavior Support Plan(s)
ABA Progress Reports
Discharge Summary from Previous ABA Provider (if applicable)

Related Service Evaluations

Speech and Language Evaluation
Occupational Therapy Evaluation
Physical Therapy Evaluation
Mental Health or Counseling Evaluations (if applicable)

Legal Documents (If Applicable)

Custody Agreement
Guardianship Documentation
Court Orders Related to Medical or Educational Decision-Making

Additional Information

Current Medication List
Any Other Evaluations, Reports, or Records Relevant to Your Child's Care

Additional Information

Anything else you would like us to know, or notes on attached reports