Pre-Assessment Interview
Client Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
My Child's Strengths:
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4
My Child’s Areas of Need:
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4
Top 3 favorite activities I like do with my child are:
“Activities” can include any time spent with your child - not just formal/structured time.
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3
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I wish I could enjoy these activities with my child but at this time, it does not seem possible:
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2
3
Have you observed overall improvement in your child’s behavior and ability to learn new skills? Please explain.
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Is there anything that you need from ABA services that you feel arenot being met?
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Do you feel like your questions are answered in a timely fashion? Do you feel that your concerns are addressed in a timely fashion? Please explain.
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In what areas/skills would you like more {Parent/guardian(s)} training and support?
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Psychological History
Please list any doctors or professionals who have evaluated or diagnosed the client
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Professional & Affiliation
Date of Evaluation or Report
Diagnosis
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*please provide a copy of any reports that are available and that may be useful in requesting authorization from insurance funder to being assessment. Example include: diagnostic reports, cognitive evaluations, IEP / re-evaluations.
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