General Intake Form

Form
Client Demographic Information:
Client Name

First NameLast Name
Client's Date of Birth
Client's Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian/Parent Name #1

First NameLast Name
Guardian/Parent Name #2

First NameLast Name
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Primary Email Address
example@example.com
Insurance Carrier
What services are you seeking from Learning Solutions?

Psychological TestingApplied Behavior Analysis TherapyOccupational TherapySpeech TherapyOther
Emergency Contacts
Emergency Contact #1

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to client:
Emergency Contact #2

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to client:
Please list those who are authorized to pick up the client:
Insurance Information:
Primary Insurance Information
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth:

MonthDayYear
Date
Insurance Company:
Insurance ID#:
Insurance Group#:
Employer:
Secondary Insurance

If applicable
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Date
Insurance Company:
Insurance ID#:
Insurance Group#:
Employer:
Credit Card Information
Name on Card

First NameLast Name
Card Number:
Expiration Date:

MonthDayYear
Date
CVV:
Family Information
Please list any legal or custody information we need to be aware of:
Primary language spoken by the family:
Primary language spoken by the child:
If the child is non-verbal, please describe how they communicate with you:
Please list any cultural or religious considerations or requests to be aware of:
Primary Concerns
What are your primary concerns?

CommunicationSibling AggressionSensory SeekingSocial SkillsFollowing DirectionsFine Motor SkillsSelf-CareBalance/MobilityHandwritingBehaviorCommunity IndependenceFeedingNon-VerbalGeneral AggressionToileting
Behaviors
Please check any of the following behaviors that apply to your child:

Cries OftenFrequent temper tantrumsAnxiousTrouble following directionsTrouble with change in routineClumsyWeak musclesPicky eaterMouths objectsDislikes hair brushingDislikes tooth brushingAvoids touch from othersDislikes playground equipmentSeems to be "on the go"Rocks selfSensitivity to lightSensitivity to soundPoor attention span
Educational Information
Are there any traumatic events that have taken place during school/educational programs that we should be aware of? If so, please explain what happened:
School/Educational Program currently attending:
Present grade level:
Does your child receive any of the following?

Special EducationBehavior InterventionOther
Services received in school:

Occupational TherapySpeech TherapyPhysical TherapyOther
Does your child have a 504 or IEP?
Does your child's teacher have any concerns with your child's development in the following areas?

Motor SkillsSocial AbilitiesSelf-Help skillsLearning Abilities
Previous Services
Has your child previously received any of the following services?

ABAOccupational TherapySpeech TherapyMental Health CounselingPhysical TherapyOther
Additional Services Information
Please provide any additional information regarding the type of services received, (including but not limited to session days, times, and a general overview of what a typical session looked like):
Therapy Goals
Please provide a brief description of what you are hoping to achieve through services with Learning Solutions:
Helpful Information
What are your child's strengths?
Please list any extracurricular activities your child enjoys engaging in:
Does your child demonstrate difficulty with separating from caregivers?
Does your child handle transition from activities well? What helps them?
Please list your child's preferred activities and/or typical routines:
Please list your child's fears and dislikes:
In your opinion, what would be helpful for your child to more easily establish trust and engage with a person/therapist?
Do you have adequate people to depend on and help you with your child when you need respite?
Please list things your child would find motivating in therapy (i.e. Stickers, treats, certain cartoon characters, etc.)
Current Skills

Select the level of performance your child can complete (Always, Sometimes, Rarely, Never)
Can independently dress self:

AlwaysSometimesRarelyNever
Needs occasional assistance to dress:

AlwaysSometimesRarelyNever
Parent dresses child on daily basis:

AlwaysSometimesRarelyNever
Can zip and button clothing:

AlwaysSometimesRarelyNever
Is starting to push arms through sleeves, legs through pants:

AlwaysSometimesRarelyNever
Feeding Skills
Uses spoons/forks at every meal:

AlwaysSometimesRarelyNever
Uses utensils

AlwaysSometimesRarelyNever
Willing to sit at a table/highchair for all meals:

AlwaysSometimesRarelyNever
Occasionally or needs reminders to use utensils:

AlwaysSometimesRarelyNever
Eats an adequate amount of food for his/her age:

AlwaysSometimesRarelyNever
Motor Skills
Appear clumsy/uncoordinated

AlwaysSometimesRarelyNever
Fatigues easily and poor endurance:

AlwaysSometimesRarelyNever
Has difficulties learning new motor skills:

AlwaysSometimesRarelyNever
Social Interaction
Plays with age-appropriate toys:

AlwaysSometimesRarelyNever
Has difficulties with transactions to new activities/environment:

AlwaysSometimesRarelyNever
Has poor frustration tolerance:

AlwaysSometimesRarelyNever
Has difficulties calming and coping with anger:

AlwaysSometimesRarelyNever
Responds when his/her name is called:

AlwaysSometimesRarelyNever
Has difficulties with change in routine

AlwaysSometimesRarelyNever
Has poor safety awareness in the community

AlwaysSometimesRarelyNever
Parental concerns about child's ability to play with other children?

AlwaysSometimesRarelyNever
Sensory Processing
Washing/Cutting Hair:

AlwaysSometimesRarelyNever
Brushing teeth/oral care:

AlwaysSometimesRarelyNever
Clothing textures/fabrics:

AlwaysSometimesRarelyNever
Avoids messy play/getting dirty

AlwaysSometimesRarelyNever
Cutting fingernails:

AlwaysSometimesRarelyNever
Loud and Unexpected Noises:

AlwaysSometimesRarelyNever
Avoids swings/climbing/movement

AlwaysSometimesRarelyNever
Do any of the following statements describe your child?
Difficulties calming down:

AlwaysSometimesRarelyNever
Engages in risky play activities:

AlwaysSometimesRarelyNever
Craves movement:

AlwaysSometimesRarelyNever
Difficulties focusing attention:

AlwaysSometimesRarelyNever
Prefers rough play:

AlwaysSometimesRarelyNever
Constantly "on the go":

AlwaysSometimesRarelyNever
Session Scheduling

Check all that apply:
Session Scheduling Availability:

8:00am-10:00am9:00am-11:00am10:00am-12:00pm11:00am-1:00pm1:00pm-3:00pm2:00pm-4:00pm3:00pm-5:00pm4:00pm-6:00pm
Birth History
Child was born:

Full TermPremature
If premature, how many weeks?
Delivery:

VaginalWith ForcepsC-Section
Were there any complications?
Was your child placed in the Newborn Intensive Care Unit? If so, for how long?
Please describe any other medical problems or complications at birth:
Medical History
Child's Primary Care Physician:
Has your child had any surgeries? If yes, please describe:
Has your child been hospitalized? If yes, please describe:
Has your child had a previous psychological evaluation? If yes, please describe:
Is your child on any medications? If yes, please describe:
Does your child use any special equipment? If yes, please describe:
Any feeding problem or nutritional concerns? If yes, please describe:
Please check all that apply to your child:

TrachHearing AidsC-LineHearing difficultyG-TubeAllergiesWears glassesLatex sensitivityVision problemsSeizures
As the client or as the client's legal guardian, I certify that the information expressed in this document is accurate to the best of my knowledge. I also declare my intent to pursue services with Learning Solutions LLC as directed by the referring physician and the BCBA case supervisor. If I plan to pay for services through an insurance company, I understand that treatment and service hours will depend on approval and authorization. If I plan to pay for services through private funds, I understand that treatment and service hours will depend on approval from whatever source promises funds.*

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Form

Client Demographic Information:

Emergency Contacts

Insurance Information:

Primary Insurance Information

Secondary Insurance

Credit Card Information

Family Information

Primary Concerns

Behaviors

Educational Information

Previous Services

Additional Services Information

Therapy Goals

Helpful Information

Current Skills

Feeding Skills

Motor Skills

Social Interaction

Sensory Processing

Do any of the following statements describe your child?

Session Scheduling

Birth History

Medical History