Prestige Behavioral Center Intake Form

Client Intake Form
Description of Services
Applied Behavior Analysis (ABA) Intervention Services: Behavior and Education Consultants (BCBAs) provide evidence-based treatment using Applied Behavior Analysis (ABA) strategies to teach new skills, develop meaningful learning tasks, address challenging behavior, and support individuals with autism in a variety of settings.

Client-Focused Skills Coaching: BCBAs work directly with the client to build specific skills. This type of therapy is only appropriate when recommended by your BCBA and may not be the best fit for all clients.

Intensive In-Home ABA Program: The BCBA works with families to develop, implement, and refine an in-home/school, intensive, comprehensive ABA-based programs individualized for each child. Home/school-based programs are implemented by behavior technicians and supervised by the BCBA.

Educational History
Is the client currently enrolled in school?
Does the child school accept ABA services?
School Name:

Program or Grade Level:
Is the client receiving or has the client received special services or accommodations at school?
If Yes, please explain what type?: (e.g. IEP, IFSP, 504 Plan)

Availability

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Times

Signature and Acknowledgement

I hereby certify that the above statements are true and correct to the best of my knowledge and understand all information in this packet will become part of the patient’s clinical file.
Email Validator
Should be Empty:

Rows	Medication, Vitamin, or Supplement Name	Purpose	Date Started	Side Effects
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Rows	No	Yes	Unsure	If yes, results?
Audiologic Evaluation
Vision Evaluation
Head Imaging (MRI, CT or Ultrasound)
EEG
Genetic Testing

Client Intake Form