ABA Clinical Interview Form
For Parents/Guardians during Initial ABA Evaluation and Semi-Annual ABA Evaluation
ABA services are an intensive program. Blurb from AZG goes here.
Email
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example@example.com
Name
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First Name
Last Name
Your child's name:
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Your relationship to the child:
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Your Child's Date of Birth:
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Month
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Day
Year
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Educational & Therapeutic Interventions History
Educational Setting History and Current Information (For children 3 years or older)
My child has never attended school in any type of setting.
My child attended school in the past but is not currently attending school.
My child is currently attending a specialized or private school.
My child is currently attending our public school system.
My child is being homeschooled.
My child is not yet 3 years old, but has attended or currently attends a day care/preschool setting.
If your child has attended school and/or currently attends school (or daycare/preschool), please list the name(s) of the school(s) or center(s) and for which grade(s) your child attended:
Has your child received/is your child receiving any of the following therapeutic interventions?
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Speech therapy
Occupational therapy
Physical therapy
ABA therapy
Feeding therapy
Hippotherapy
Play therapy
My child has not received any of these therapies
Other
If your child has received or is receiving any of the above therapies, please list the provider/agency name, type of therapy, frequency of therapy each week, and whether this is previous provider or current provider information:
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Medical & Health History
Does your child have a history of or are they currently experiencing any acute or chronic health concerns (e.g., asthma, seizure disorder, diabetes, etc)?
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Yes
No
If yes, please provide the condition, diagnosing physician/clinician, and date of diagnosis below. If none apply, please write n/a.
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Is your child currently taking any prescribed medications, herbal supplements/vitamins, or over-the-counter medications?
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Yes
No
If yes, please list all medications and/or supplements, their dosage, and the purpose for your child taking them. If none apply, please write n/a.
Does your child have any known drug, food, or environmental allergies?
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Yes
No
If yes, please describe the severity of the allergy and the prescribed action plan to treat the allergy (e.g., EpiPen, Benadryl, etc). If none apply, please write n/a.
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Dietary Information & Meal Times Behavior
Please list any dietary restrictions or limitations your child has (e.g., gluten-free diet, soy-free, dairy-free, vegetarian, vegan etc). If none apply, please write n/a.
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Would you describe your child as a 'picky eater'?
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Yes
Sometimes
No
Please list foods that your child typically eats on a regular basis:
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Does your child exhibit any interfering/problem behaviors during meal times?
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Yes
Sometimes
No
If yes, please describe the mealtime behaviors. If none apply, please write n/a.
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Sleep Patterns & Behaviors
How many hours of sleep on average does you child get per night?
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Less than 6 hours
6-8 hours
8-10 hours
More than 10 hours
Where does your child sleep at night for the majority of the time?
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Their own bed in their own room
Their own bed in a shared room
Parents/Guardian's bed in the parents/guardian's bedroom
Combination of parents/guardians' bed and their own bed
How would you describe your child's bedtime behaviors and sleep patterns?
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Social Interaction, Challenging Behaviors, & Preferences
Does your child exhibit any behaviors currently that you consider to be significantly interfering or problematic?
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Yes
Sometimes
No
If yes, please describe (e.g., self-injurious behaviors, aggression towards others or property, elopement, strict adherence to routines, repetitive behaviors, etc). If none apply, please write n/a.
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If yes, how do you typically handle these behaviors?
How would you describe your child's social interaction with other children (including siblings)? Do they seek out other children? Do they engage in parallel or interactive play?
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Please list some of your child's highly preferred toys, items, activities, people:
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Family Dynamics & Social History
What is the primary language spoken in the home?
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What language is used by family members when speaking to your child?
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Please list all the people who live in the same house as your child: (1) if your child has siblings, please indicate if they are older or younger; (2) if you and your spouse/partner are separated/divorced, please indicate how much time is spent with each parent/guardian per month.
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Has your child or family experienced any significant life events in the last 12 months (e.g., moving to a different house, relocation to a different area/state/region, change of caregiver/nanny, addition of baby sibling, loss of a loved one, change in marital/parenting status, etc.)? If yes, please describe:
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Are there any specific family, socio-cultural, or religious considerations that you would like to make us aware of that may impact your child? If yes, please describe:
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What are your top three desires for your child over the next 6-12 months?
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Please feel free to add any information you would like the evaluator to know that was not covered in this form:
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Submit
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