ABA INTAKE QUESTIONNAIRE
Language
  • English (US)
  • Haitian Creole
  • Español

  • 14565 Sims Rd

    Delray Beach, FL 33484

    aba@littlechampstherapy.com

    Phone: 561-494-4499 Fax: 561-705-7501

  • ABA INTAKE QUESTIONNAIRE

  •  / /
  •  / /
  • Gender
  •  - -
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status
  • Format: (000) 000-0000.
  • Has your child ever had a previous ABA evaluation ar any facility.
  •  / /

  • HEALTH AND DEVELOPMENTAL HISTORY

  • Birth Weight

  • Lbs. Oz.      

  • At what age did child begin to crawl?

  • year(s). month(s).      

  • At what age did child begin to walk?

  • year(s). month(s).      

  • At what age did child begin to babble?

  • year(s). month(s).      

  • At what age did child begin to use single words?

  • year(s). month(s).      

  • At what age did child begin to use single sentences?

  • year(s). month(s).      

  • At what age did child begin self-feeding?

  • year(s). month(s).      

  • Childhood Illness
  • Is there a history of mental illness in the family?
  • Rows
  • Rows
  • Rows

  • CURRENT PROBLEM

  • Check all the concerns that have brought you to Little Champs

  • How long has this been a concern?

  • year(s). month(s).

  • Age at which problem was noted:

  • year(s). month(s).

  • Does anyone else in your family have a similar problem?
  • What treatments has your child received for this concern or problem:
  • Was this treatment effective at reducing the problem?

  • Please describe the duration of this treatment:

  • year(s). month(s).

  • EDUCATIONAL HISTORY

  • Attended/Participated in Early Intervention Program (before age 3)
  • Attended pre-school?
  • Attended kindergarten?
  • Attended elementary
  • In any special classes
  • Repeated grade?
  • Ever suspended/expelled?
  • Ever had psychological testing at school?
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Please list all individuals living in the same household with child.

  • Gender
  • Relationship to child
  • Gender
  • Relationship to child
  • Gender
  • Relationship to child
  • Gender
  • Relationship to child
  • Gender
  • Relationship to child
  • Gender
  • Relationship to child

  • Thank you for filling out this questionnaire.

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