ABA Initial Contact Form

Please fill out this form as completely as possible. This information will assist in the assessment process. If you need any assistance with completing this form, please contact Let's Put Our Kids First via phone at (804) 592-6877 or email at info@letsputourkidsfirst.com.

*Let's Put Our Kids First is committed to the privacy of its consumers. All forms are HIPPA compliant to protect your privacy.

Person completing the intake form

Relation to the person referred for treatment

How did you hear about us

Client Information Full Name

Date of Birth

Date

Preferred pronouns may be used (select all that apply): in therapy in documentation/communications with other providers with other family members Primary language spoken at home: blanks Other languages spoken Type a label . Diagnosis blank .

Additional Diagnosis

Have you shared the above diagnosis with friends and family?

School/Daycare Name (if applicable)

Grade (if applicable)

Primary Teacher/ School Contact Name

Responsible Party Information Guarantor's Full Name

Relation to Client

Prefix

Primary language spoken

Other languages spoken

Phone Number

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Personal Email

example@example.com

Work Email

example@example.com

Reason for Referral: Have you heard of applied behavior analysis (ABA) therapy?

If so, have you received ABA services in the past?

When?

Did you find it beneficial?

Please describe any behavioral concerns (i.e., behaviors that are dangerous and/or impede on using functional Communication or learning new skills) that have led toseek treatment.

How do you and others respond to these behaviors? Please indicate the client's (person being referred for treatment) current communication skills (e.g., spoken words, sign language, picture cards, etc.:

Please describe what you would like to get out of treatment. Please be as descriptive as possible.

Please describe any cultural, religious, ethnic, or social beliefs about mental health or illness that you feel would help us in understanding how to best support you and your family. Is there any other information you would like for us to know?

Let's Put Our Kids First ABA Initial Contact Form