INTAKE INTERVIEW FORM
Select and Option Below:
Where you would like services?
Services in Southwest Louisiana:
Home Services
Office Services
School and Community Services
Services in Southeast Texas:
Home Services
Office Services
School and Community Services
Client Information:
Name
First Name
Last Name
Sex:
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis:
Parent/Caregiver Information:
Name
First Name
Last Name
Relationship:
Phone:
E Mail:
example@example.com
Address:
Insurance Information:
Provider:
Phone Number:
Policy/Member Number:
Phone Number:
Primary Care Physician:
Phone:
Other Treating Professionals (Past and Present) - Include any Counseling, Occupational Therapy, ABA, Speech, Educational Services, Etc. Provider Name Company
Rows
Provider Name
Company
Service
Phone
Dates in Treatment
1.
2.
3.
4.
5.
School Information:
School:
Grade:
Teacher:
Contact:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Supplemental Questionnaire:
List Medication Names, Dosages, Administration Notes/Schedule, and Duration (How long have they been taking this medication?)
Medical
Rows
Answer
Any history of seizures?
Any allergies?
Medication side effects?
Vision Impairments?
Hearing Impairments?
Motor Impairments?
Nutritional Intake?
Hospitalizations?
Notes/Other
Current Concerns, Supplemental Questionnaire Continued:
Rows
Answer
Who referred you to Lights on ABA Services (Name, agency, phone #)?
Current Parental Concerns & Problems Related to Diagnosis
Favorite Activities/Preferences
Communication
(How does your child communicate his wants and needs to you?)
Instruction Following
(What types of instructions does he/she have difficulties following? What instructions does he/she successfully follow?)
Engagement in Activities
(What are some activities that he/she enjoys to engage in, does not enjoy engaging in?)
Are you willing to participate in frequent (weekly, bi-weekly) family training? (If yes, how many family members would be attending?)
Is the client currently or has a history of alcohol or drug use/abuse?
For clients 12 years and above.
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Family, History
Rows
Answer
Caregivers, Names and Relationships
Siblings, Names and Ages
Any legal issues?
Any spiritual variables?
Any cultural variables?
Notes/Other?
Paternal Medical History
Paternal Behavioral-Health History
Maternal Medical History
Maternal Behavioral-Health History
Primary Language
Transportation Needs
Has the Individual Had A History of Sexual Abuse/Assault
Any racial variables that need to be considered for treatment?
Should be Empty: