Prospective Client Form
Thank you for your interest in Aloha Behavioral Practice. We'd like to learn about how we can be of service to you. Please complete this intake questionnaire regarding your child and their needs.
General Information
The following section will ask you to provide general information, such as your name and relationship to the child.
Name of Individual Completing this Form
*
First Name
Last Name
Name of Child
*
First Name
Last Name
Relationship to the Child
*
Parent/Guardian
Uncle/Aunt
Grandparent
Child's Date of Birth
*
-
Month
-
Day
Year
Date
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Parent/Guardian Contact Information
Please provide your contact information below.
Parent/Guardian 1
*
First Name
Last Name
Parent/Guardian 2
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Email Address
*
example@example.com
Parent/Guardian 2 Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Email Address
example@example.com
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Medical Information
The following section will inquire about the child's current physician and medical history.
Name of Child's Physician
*
First Name
Last Name
Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any current health conditions, including infectious diseases?
*
Yes
No
If yes, please describe below.
Does your child have any known medical conditions?
*
Yes
No
If yes, please list the conditions below.
If your child has received treatment for the conditions mentioned above, please provide the providers and durations of previous treatment.
If your child is currently receiving treatment for the conditions above, please provide the name(s) of the current treating clinician(s).
If your child is experiencing any therapeutic interventions, please mention below and include their response(s) to the interventions.
List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child/adolescent has had below.
Does your child have any vision problems?
*
Yes
No
If yes, please explain below and if there are any treatments currently being used for correction.
Does your child have any hearing problems?
*
Yes
No
If yes, please explain below and if there are any treatments currently being used for correction.
Does your child have a history of seizures?
*
Yes
No
If yes, please describe the types of seizures and current treatment.
Is your child currently taking any medications?
*
Yes
No
If yes, please name the medication(s) and the amount taken per dose.
If your child takes medication(s), please note how often they are taken below.
If your child takes medication(s), please note when they take the medication.
Does your child experience side effects as a result of taking their medication(s)?
*
Yes
No
If yes, please describe the side effects below.
Does your child have any allergies to medications?
*
Yes
No
If yes, please describe below, including any adverse reactions.
Does your child currently have a diagnosis?
*
Yes
No
If yes, please provide the following information as prompted.
Please note that the diagnosis information is required for insurance coverage. By having this information, it assists us when speaking with your insurance company to get authorization for services and providing you with invoices for reimbursement through insurance.
If your child has a diagnosis, please name the diagnosis/diagnoses and the diagnosis code the diagnosing physician(s).
If your child has a diagnosis, please indicate the date they received the diagnosis/diagnoses.
If your child has a diagnosis, please name the diagnosing physician(s).
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Insurance Information
This section will inquire about your insurance, including the name of your insurance company and Social Security Number.
Name of Insurance Company
*
Insurance Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Policy Holder
*
First Name
Last Name
Social Security Number
*
Policy Holder's Date of Birth
*
-
Month
-
Day
Year
Date
Member ID
Group ID
Please provide us with a copy of the front and back of your insurance card if you are going to be seeking reimbursement for services through your insurance company.
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Current/Previous Therapy Provider Information
Please provide us with information regarding the following types of current or previous therapy providers and copies of any recent evaluations that indicate dates of previous treatment and therapeutic interventions and responses.
Does your child currently receive behavioral services with another provider?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
Does your child currently receive speech therapy services?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
Does your child receive occupational therapy services?
*
Yes
No
Are you interested in occupational therapy services with us?
Yes
No
If yes, please provide the provider's name, address, phone number and email.
Does your child currently receive physical therapy services?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
Does your child currently receive psychiatric services?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
Does your child currently receive any other services?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
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Educational History
Please provide the names of all schools your child/adolescent has attended in order starting with the most current school.
Name of Current School
Is your child's current school a part of the public or private school system?
*
Public Education System
Private School System
How many years has your child attended their current school so far?
What is your child's current grade at this school?
Does your child's current school offer Special Education Services?
Yes
No
What was the name of your child's previous school?
Was your child's previous school a part of the public or private school system?
Public Education System
Private Education System
How many years did your child attend their previous school?
From what grades did your child attend their previous school?
Did their previous school offer Special Education Services?
Yes
No
Is your child currently classified for Special Education Services?
*
Yes
No
Please provide us with copies of any reports from evaluations that you may have, as well as a copy of the current 504 plan or IEP.
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Family Background
Please provide information about your child/adolescent's family background as prompted.
Does either parent/guardian’s job require him/her to be away from home for long hours or extended periods of time that might prevent them from being involved in ABA services and parent training?
*
Yes
No
If yes, which parent/guardian and for how long?
What is your marital status?
*
Married
Civil Union
Remarried
Divorced
Separated
Widowed
Single
Cohabitants
If divorced, who has legal custody?
If divorced, is it full or joint custody?
Does your child have siblings?
*
Yes
No
If yes, please list the name(s) and age(s) of their sibling(s) and indicate if they live at home.
Are you also interested in seeking services for any of the siblings with special needs? If yes, you will need to complete this form again for that child.
*
Yes
No
Are there any other individuals residing in the house or that play a significant role on how this child is raised?
*
Yes
No
If yes, please identify who else is involved in raising the child and their relationship to the child.
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Psychological History
The following section will ask questions about the psychological history of the child/adolescent and their immediate and extended biological family.
Please indicate below whether there is a history of the following in your immediate family or in either biological parent’s extended family.
Autism Spectrum Disorders
Learning Problems/Disabilities
ADD/ADHD-Attention Problems
Clinical Depression
Bipolar Disorder
Behavior Problems in School
Anxiety Disorders (e.g., OCD, etc.)
Psychosis/Schizophrenia
Substance Abuse/Dependence
If any of the above are checked, please indicate who in the family currently has or has had these diagnoses.
If you have other mental health concerns, describe them below.
Has your child had an outside psychological or psychiatric evaluation?
*
Yes
No
Has your child ever been hospitalized for a psychiatric condition?
*
Yes
No
Please provide us with any other information on the psychological history that you feel would be helpful to us in understanding your child.
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Birth and Development History
The following section will inquire about the birth and development of the child/adolescents.
Were there any complications with the pregnancy?
*
Yes
No
If yes, please describe the complications below and treatment details.
Was birth at full term?
*
Yes
No
If no, please provide details.
Were there any complications during delivery?
*
Yes
No
If yes, please describe the complications below and treatment details.
Were there any concerns at birth?
*
Yes
No
If yes, please describe the concerns and treatment details.
Where there any developmental milestones that your child/adolescent was delayed in or did not achieve?
*
Yes
No
If yes, please identitfy those milestones below.
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Current Behavioral Concerns
Please indicate if your child/adolescent engages in any of the following behaviors. Check all that apply.
Aggression
Hitting (e.g., punch, slap, etc.)
Kicking
Biting
Pinching
Head-butting
Scratching
Spitting
Other
Self-Injurious Behavior
Hitting self with hands or fists
Kicking self
Biting self
Head-butting walls, windows, etc.
Pulling teeth
Scratching skin
Cutting/burning
Other
If your child/adolescent hits, kicks, or bites themselves, please indicate where on the body this behavior is engaged.
Does your child/adolescent engage in property destruction?
*
Yes
No
If yes, please describe below.
Does your child elope (i.e., running out of a building, room, vehicle, etc.)?
*
Yes
No
Does your child experience sensory issues?
*
Yes
No
If yes, please describe below.
Does your child engage in sexualized behaviors?
*
Yes
No
If yes, please describe below.
Does your child engage in any of the following? Check all that apply.
Self-urinating/defecating
Fecal smearing
Rectal digging
Defiance or problems with authority
Tantrums
Screaming/yelling
Vocalizations
Repetitive behaviors
Fire setting
Additionally, please indicate if your child is experiencing any of the following. Check all that apply.
Difficulty with toileting
Problems with eating
Isolated socially from peers
Difficulty making friends
Problems keeping friends
Difficulty concentrating
Problems with sleeping
Bedwetting
Anxiety
Sadness or depression
Hallucinations
Delusions
Suicidal ideation/Attempts
If your child has problems with sleeping, please describe below.
Has there been any current or past relevant legal issues pending with your child?
*
Yes
No
If yes, please describe below.
Has there been a history of any of the following? Check all that apply.
Physical abuse
Sexual abuse
Alcohol use/abuse
Drug Use/Abuse including nicotine and/or illegal drugs
If there is a history of drug abuse, please list the drugs below.
Is there any additional information you would like for us to know?
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Parent Goals for Child
Please answer the questions below using the option on the right that best describes what you may have noticed in your child over the past six months.
How often does s/he have difficulty staying organized?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he have problems remembering things?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he fidget or squirm when required to stay seated?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he make careless mistakes?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he have difficulty paying attention during boring or repetitive tasks?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he misplace items?
*
Never
Rarely
Sometimes
Often
Always
How often is s/he distracted?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he interrupt others who are talking?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he have trouble unwinding after an activity or day?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he have trouble waiting his/her turn?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he appear to “space out”?
*
Never
Rarely
Sometimes
Often
Always
What do you hope to gain from assessment / treatment?
*
What goals do you have for your child as s/he grows into an adult?
*
What are areas of strengths for your child?
*
Do you have any worries or concerns about moving forward with assessment/treatment?
*
Yes
No
If yes, please describe.
What are your specific goals for language?
*
What are your specific goals for behavior?
*
What are your specific goals for social?
*
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Reinforcer Checklist
Please review the following items and check the appropriate line indicating whether or not your child enjoys the items listed and would be motivated by them as a possible reward/reinforcer. Then list specific types or examples of each potential reinforcer.
Does your child have edible reinforcers?
*
Yes
No
If yes, please indicate the types of edible reinforcers. Check all that apply.
Salty
Sweet
Spicy
Sour
Beverages
Other
If any of the above are checked, please provide examples below.
Does your child have tangible reinforcers?
*
Yes
No
If yes, please indicate the types of tangible reinforcers. Check all that apply.
Toys
Games
Computer
iPad
Movies
TV Shows
Music
Materials
Other
If any of the above are checked, please provide examples below.
Does your child have social reinforcers?
*
Yes
No
If yes, please indicate the types of social reinforcers. Check all that apply.
Interacting with parents/guardians
Interacting with siblings
Interacting with other family members
Interacting with friends
High fives
Verbal praises
Other
If any of the above are checked, please provide examples.
Does your child have activity reinforcers?
*
Yes
No
If yes, please indicate the types of activity reinforcers.
Going out in the community
Singing songs
Playing teacher
Indoor activities
Outdoor activities
Other
If any of the above are checked, please provide examples.
Does your child have automatic reinforcers?
*
Yes
No
If yes, please indicate the types of automatic reinforcers. Check all that apply.
Spinning
Staring at lights
Twirling hair
Rocking
Other
If any of the above are checked, please provide examples.
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How many hours are you seeking for ABA Services and What time of day?
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