ABA Intake Form "*" indicates required fields Step 1 of 2 50% HiddenDate MM slash DD slash YYYY Client's Name* Date of Birth* MM slash DD slash YYYY Name of Person Completing* Relationship with Client* Client's Diagnosis* Who gave the Diagnosis?* Date* MM slash DD slash YYYY Medical Information1- Does your child currently go to school?* Yes No School Name* Program Type* Regular Special Classes Special Program 2- Does your child currently receive any therapies or special services?* Yes No Please indicate which program* Speech OT Physical Therapy Feeding Other Speech Therapy Frequency OT Frequency Physical Frequency Feeding Frequency Please list what other therapy and the frequency 3- Please list any current medications* Add Remove4- Please list any allergies* Add Remove5- Does your child have any special diet/ restrictions?* Yes No 6- Does your child feeds itself?* Yes No 7- Does your child Use any of these?* Bottle Sippy Cup None 8- Does your child have any sleep disorder?* Yes No 9- Is your child toilet trained?* Yes No 10- Does your child have an Individual Education Plan (IEP)??* Yes No 11- Place of Birth* 12- People he/she lives with* 13- Description of the home* Skill & Personal Care14- Walks alone?* Yes No 15- Can your child go up and down stairs without help?* Yes No 16- Does your child need assistance with activities of daily living?* Yes No 17- Does your child eats all kinds of food?* Yes No 17.a- Please list food preferences* 18- Does your child brush his/her teeth alone?* Yes No 19- Does your child comb his/her hair alone?* Yes No 20- Does your child dress alone?* Yes No 21- Does your child respoind by his/her name?* Yes No Communication22- Does your child babble or make sounds throughout the day?* Yes No 23- Does your child use words to communicate?* Yes No 24- If your child does not easily use words to communicate, please briefly summarize the child's language abilities.(known words, known sounds, amount of words said each day, etc.) Receptive Assessment25- Does your child respond to his/her name when you call it?* Always Sometimes Never 26- If you tell your child to get his/her shoes or pick up his/her cup, does he/she follow your direction without gesture?* Always Sometimes Never 27- If you tell your child to sit down or clap their, will they follow the direction?* Yes No 28- Will your child touch his/her body parts, for example if you say "Touch your nose" will the chill do it?* Yes No 28.a- Please list the body parts your child can identify. Echoic Assessment29- Can your child imitate single words you say?* Yes No 30- Will he/she imitate phrases?* Yes No 30- Does your child say things he/she has heard you say in the past?Manding Assessment31- Can your child ask for things he/she wants with words?* Yes No 31.a- Please lis the items/activities the child can request with words.31.b- If your child cannot ask for things he/she wants or needs, how does he/she usually let you know what they want?(crying, tantrums, gestures, pointing, sign language, etc.)Tacting Assessment32- Can your child label things in a book or on flashcards?* Yes No 33- Can your child label common items intheir environment like, couch, TV, shoe,coat, etc.?* Yes No Please estimate the number of things your child can label and give a few examples.* Intraverbal Assessment34- Can your child fill in the blanks to songs? For example, if you sing “Twinkle, Twinkle Little _______” will your child say “Star”.* Yes No 35- Please list songs or words that your child can fill in. 36- Will your child fill in the blanks to fun and/or functional phrases such as filling in “Pooh” when he/she hears “Winnie the ______” or say “Bed” if asked “What do you sleep in?”* Yes No 37- Will your child answer WH questions (with no picture or visual cue) such as What flies in the sky”, “What goes in the kitchen”?* Yes No 38- Can your child name at least 3 colors or animals if asked?* Yes No Imitation Assessment39- Will your child copy your actions with toys if you tell him/her “Do This”? For example, if you take a car and roll it back and forth and tell your child “Do This” will your child copy you.* Yes No 40- Will your child copy motor movements such as clap hands or stomp feet if you do it and say, “Do This”?* Yes No Visual Skills Assessment41- Will your child match identical objects to objects, pictures to pictures, and pictures to objects if you tell him/her to “match”?* Yes No 42- Can your child complete age appropriate puzzles?* Yes No Social Skills43- How does your child relate to his/her peers and other people?* Excellent Good Fair Poor 44- Does your child share toys?* Yes No 45- Does your child participate in cooperative play?* Yes No 46- Does your child know how to wait for their turn?* Yes No 47- Does your child have visual contact?* Yes No 48- Does your child know how to ask forpermission?* Yes No 49- Does your child follow rules?* Yes No 50- Can your child follow simple instructions?* Yes No 51- Does your child follow social norms?* Yes No 52- Please describe your child’s daily routine.Physical and Medical State53- Your child was born by:* Normal Delivery C-Section 54- Where there any complications at birth?* Yes No 54.a- Please explain*55- Name of Primary Doctor* 56- Name of Neurologist* 57- Name and Specialty of any other Specialist. Add Remove58- Other Medical Conditions Add Remove59- Has your child received and prior treatment?* Yes No 59.a- Please explain60- Family Concerns61- Please list any problem behaviors thatyour child displays. Physical Aggression Off Task Behavior Task Refusal Elopement Tantrum Physical Aggression - Please estimate the number of times thebehavior happens. Ex. 10 times a week. Off Task Behavior - Please estimate the number of times thebehavior happens. Ex. 10 times a week. Task Refusal - Please estimate the number of times thebehavior happens. Ex. 10 times a week. Elopement - Please estimate the number of times thebehavior happens. Ex. 10 times a week. Tantrum - Please estimate the number of times thebehavior happens. Ex. 10 times a week. 63- Describe what strategies you have tried to control these behaviors and whether or not thestrategies were successful.Strengths64- What is your child good at?65- What does your child like to do most?Weaknesses66- What does your child NOT good at?67- What does your child NOT like to do? Caregiver's Name Caregiver's SignatureWitness Name Witness' Signature
