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ABA Therapy Intake Form
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Clinic Location

RoswellKennesaw
Identifying Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Person completing this form:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Parent/Guardian Name(s)
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Mother's Occupation
Father's Occupation
Child live with both parents

YesNo
Primary language spoken in home
Others living in the home (names, ages, and relationship to patient)
Pediatrician
Pediatrician's Phone Number
Please enter a valid phone number.
Psychologist
Date of Last Evaluation

MonthDayYear
Reason for referral
Previous evaluations (list)
Therapy to date (list)
Describe the present problem
Who noted the present problem?
When?
How does the family react to the problem?
Have there been any significant changes in the last six months? If so what?

Client's Interest

Please indicate anything that the clinicians should know when working with your child.
Preferences (favorite activities, food, interests, topics, sensory)
Dislikes (aversions)
Other - Including any information regarding your child's interests you want us to know!

Concerns
Reason for seeking ABA services (please explain):
Please list the client's strengths:
Developmental Concerns

Please indicate by explaining each that applies to your child.
Cognitive/Learning:
Motor:
Behavior:
Language:
Social:
Peer Interaction:
Play/Leisure:
Academics (Reading/Writing/Math):
Executive Functioning (Organization/Flexibility/Attention):
Other:
Parent/Family Preferences

Please list the top three areas/goals you would like to see improvement for the client in the next 6 months:
1)
2)
3)
Current Therapies
Type a question

Speech TherapyOccupational TherapyPhysical TherapyOther
Cultural Considerations
Please describe below any important cultural practices, rituals, traditions, or beliefs that you believe are important for us to be aware prior to initiating a therapeutic relationship.

ABA Therapy Intake Form