Intake form English ACI version 4-juli 2022 (1)

To whom it may concern

Thank you for your application for care at ABA Center International (aka ACI) We ask you kindly to fill in the intake form below. Please send relevant reports and diagnostic information to:

admin@abacenterinternational.com. We will contact you in order to plan an intake.
Date

MaandDagJaar
Datum
Filled in by
Name
Nickname
Birthdate

MaandDagJaar
Datum
Address

Address

Street Address Line 2

CityState / Province

Postal code
Telephone number
Format: (000) 000-0000.
Birthplace
BSN (Social security number NL based)
Nationality
Document number
Form of ID
Expiration ID
Date of proof of identification

MaandDagJaar
Datum
Details parents/caretakers Name mother
Name mother
Parental authority yes/no
Address
Telephone number
Format: (000) 000-0000.
E mail address
voorbeeld@voorbeeld.com
Name father
Parental authority yes/no
Address
Telephone number E-mail address
Format: (000) 000-0000.
E mail address
voorbeeld@voorbeeld.com
Additional Information
Health Insurance provider
Policy number
Family physician
Address
Telephone number Pharmacy
Format: (000) 000-0000.
Pharmacy
Address
Telephone number
Format: (000) 000-0000.
Aanmelding Reason for applying for care at ACI
Reason for applying for care at ACI
Goals of referral
When applicable: goals/treatment needs of youth according to the refering party. Approval registration youth?
When applicable: goals/treatment needs of youth according to the refring party
Goals/treatment needs according toparents. Approval registration parents/caregivers?
Goals/treatment needs according to parents. Approval registration parents/caregivers?
Short description professional treatment history
Current treatment situation
Are you experiencing challenges in the upbringing of your child? If yes, which problems?
Is there professional care or treatment in place via a professional organization, school and/or workplace? Please explain.
Strengths Positive qualities, skills, support, achieved results, motivation
Risk factors: Drugs, alcohol, finances, sexuality, social pressure/network, attachment, psychiatric background parents, addiction parents, relationship challenges parents
Diagnostics
Diagnostics/disorders Diagnosis, date, tested by

MaandDagJaar
Datum
IQ Verbal, performal, total, tested by
Social Emotional developmental age, Date, tested by

MaandDagJaar
Datum
Describe your child's favorite activities and favorite toys
PECSTabletVerbalPointingCryingOther
Which language is spoken at home?
School (name & location)
YesNo
Specific wishes, agreements or action
General risk-inventory habits /problem exploration
Safety risks present (in the neigborhood)
Agressive behaviorSelf harmEats or smears faecesRuns away outdoorsRuns away from homeTantrumsToilet trainedAndere
Physical health: Challenges pertaining to age, Sleep challenges, challenges in daily living skills, Healthy eating/ Diet challenges, Frequently occuring illnesses within the family, Overweight/underweight Allergies
Mental wellbeing: Psychiatric disorders, psychosocial challenges, (social) resilience
Emotional regulation: Verbal aggression, fysical aggression towards people or materials, automutilation
Social wellbeing: Leisure activity, social network, loneliness
Substance abuse: Smoking, alcohol use, soft drug use, hard drug use, (online) gaming, gambling, Frequency Addiction treatment
Medication use Therapy compliance, complaints of long term use of medication, Refusal of medication, Non prescription medication
Is there a risk of causing a nuisance to others in the neigborhood?
Is there an actual risk of committing suicide?
Relationship and sexuality sexual transgressive behavior, commission of a sex crime, possible sexual abuse/intimidation, (social) resilience issues, sexually tinted behavior
Other information and comments
Availability

Availability for ABA-treatment (note all hours of availability- the more hours you fill in the greater the chance of starting treatment sooner)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
If there is less availability than four days per week for ABA treatment, please share the reason why.
YesNo
Are there challenges to planning at least 10 hours of ABA treatment per week?
Are there challenges in following ABA treatment for a period of at least 6 months?
YesNo
HomeSchoolABA Center International, location AmsterdamOther. Please fill in:
For how many days and during which times?
Days
Times of availability
YesNo
Private schoolPublic school
What are the vacation dates planned in the comin year?
Are there medical situations affecting availability?
YesNo
Care indication
YesNoAndere
Private payWLZPGBContract MuinicipalityOther, namely:
YesNo
YesNo
Organisation
How long and what was the reason for discontinuing the treatment?
Year
Reason
Should be Empty:

Additional Information

Aanmelding Reason for applying for care at ACI

Diagnostics

General risk-inventory habits /problem exploration

Availability

Care indication