Respite Intake Form
Please answer all questions to the best of your ability.
Client
Name
*
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Diagnosis and presenting problem
Feelings
Restless
Sullen
Fearful or anxious
Sad or cries easily
Irritable or angers easily
Bored
Carries guilt or shame
Other
Behavior
Problems in school
Lacks interest in things
Engages in sexual play with others or toys
Threatens to harm others or animals
Destroys possessions or other property
Steals
Refuses to talk
Sets fires
Overactive
Has been in trouble with police
Self-destructive
Disrobing
Elopement
Other
Social Interactions
Prefers to be alone
Difficulty making and keeping friends
Defiant, discipline problem
Aggressive
Argues excessively
Refuses to go to school
Other
Thinking
Frequently confused
Daydreams excessively
Distracted, does not pay attention
Mistrustful
Sees or hears things that are not there
Blames others for misdeeds or thoughts
Talks about death or suicide
Frequent memory loss
Bizarre thoughts
Schoolwork is slipping
Other
Education
Individualized Education Plan (IEP
Behavior Intervention Plan (BIP)
504 plan
Functional Behavior Analysis (FBA)
Receives one-to-one support
Special education classroom
Emotion/behavior focused classroom
ESL/English learner
ABA services
School-provided communication device
Modified schedule
Occupational therapy (OT)
Other
Medical and Physical
Autism Spectrum Disorder
Down Syndrome
Traumatic brain injury
Lacks energy
Uses laxatives
Vomits frequently
Food refusal or secretive eating
Frequent stomach aches
Headaches
Excessive weight loss or gain
Sleep problems
Seizures
Other
Additional Medical Information
Other Important Information
Accident-prone
At-risk for out-of-home placement
Subjected to neglect
Subjected to sexual abuse
Subjected to emotional abuse
Subjected to physical abuse
Currently in treatment for mental health
Currently using substances
Previously used substances, not currently
History of hospitalizations for mental health problems
Non-verbal
Requires assistance to use the restroom
Other
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Contacts
Preparer
Please provide the contact information for the person who prepared this intake
Relation to client
Caregiver
Case manager
Social Worker
Other
Preparer Name
*
First Name
Last Name
Preparer Email
*
example@example.com
Preparer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver Contact
Caregiver Name
First Name
Last Name
Caregiver Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver Email
example@example.com
Caregiver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Case Manager
Case Manager Name
First Name
Last Name
Case Manager Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
Social Worker
Social Worker Name
First Name
Last Name
Social Worker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Social Worker Email
example@example.com
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emgergency Contact Email
example@example.com
Authorized Persons
Any persons Trace is authorized to release your child to.
Authorized Person
First Name
Last Name
Authorized Person Email
example@example.com
Authorized Person Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Respite Services
Are there any medications in the home that are accessible to the client?
Yes
No
Will the client need medications during the appointment?
Yes
No
If yes, who will administer the medications?
Are any of the following items in the home?
Gun
Knives (other than kitchenware)
Explosives
Taster/stun gun
Mace/pepper spray
Other
Provide the days, times, and locations of respite services.
Specific do's and dont's
Interests and activities
Elopement plan
Physical aggression plan
Any additional information
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Requested Schedule
Provide your preferred schedule for services. This is a starting point for us to begin services and is free to change in the future.
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Respite Authorizations and Policies
Release of information
*
I hereby authorize Trace Behavior Support to release and exchange the above named client's information with other mental health professionals and schools districts involved in this client's care. I understand that these records are confidential under applicable law and cannot be disclosed without my written consent unless provided for by law. This authorization expires when client is discharged from our program (or within 90 days) unless previously revoked by me in writing. I/we understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it.
Consent to treatment
*
I authorize the designated staff of Trace Behavior Support to provide behavioral intervention and stabilization services, and other related forms of service, including but not limited to behavioral intervention including emergency manual restraint, transportation, recreational services and emergency medical care they deem necessary.
Cancellation
*
I understand that there are no refunds unless Trace Behavior Support cancels the scheduled service. All services will be scheduled no later than 4:00 pm the prior Thursday.
Minimum Duration
*
I understand that Trace Behavior Support requires a 3 hour minimum for all respite appointments.
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