AIA Learner Pre-Assessment Form
Please complete ALL the questions within the following Intake form to determine the best quality service experience for your child. Your Client Advocate will contact you within 24-72 hours upon completion.
Assigned Arizona Institute for Autism Client Advocate: Jennifer Bonefont
Child Name
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First Name
Last Name
Child Date of Birth
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Month
-
Day
Year
Date
Parent/Guardian Name
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First Name
Last Name
Parent Guardian Relationship to Child
*
Primary Email Address
*
example@example.com
Parent/ Guardian Name
*
First Name
Last Name
Parent Guardian Relationship to Child
*
Secondary Email Address
example@example.com
Family Life
Are there any current, relevant Legal issues involving the child and /or family, not limited to divorce, custody, and /or guardianship issues?
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Sibling/(s)(Names/ages):
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Other than parents and siblings, who lives in the home:
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List any cultural or spiritual practices that may limit ABA therapy, if any
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In Regards to the in-home services, once services starts, the case BCBA will discuss environment and family dynamics, that ensure session effectiveness. Please list questions you may have!
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List sIgnificant Pre- and Perinatal Events.
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Medical History
What are the Medical diagnoses for your child including Autism, ADHD, and other Learning Disabilities?
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Name of Provider who diagnosed the child with Autism?
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First Name
Last Name
Provider who Diagnosed Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Provider who Diagnosed Phone Number
Please enter a valid phone number.
Provider who Diagnosed Phone Email
example@example.com
Date of Diagnosis
*
-
Month
-
Day
Year
Date
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Is the child using any medication(s)? Please list names of medication(s), dosage, and frequency
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Is there any family history of medical, developmental, learning, emotional, mental health, or psychiatric difficulties?
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Has the child ever received any ABA treatment before? Please mention the name of the facility and weekly hours received.
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Has the child a present or past seizure history. Please explain!
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Name of Pediatrician Provider
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First Name
Last Name
Pediatrician Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pediatrician Provider Phone Number
*
Please enter a valid phone number.
Pediatrician Provider Email
example@example.com
Name of Developmental Doctor Provider
First Name
Last Name
Developmental Doctor Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Developmental Doctor Provider Phone Number
Please enter a valid phone number.
Developmental Doctor Provider Email
example@example.com
Does your child receive any additional services including Speech Therapy, Physical Therapy, Occupational Therapy, or ABA Therapy? Please mention the name of the facility and the frequency.
*
School Information
School Name
Educational Placement (General Education, Special Education, Self-Contained, or others)
Grade
School Time
School Days Attending
Does the child currently have an IEP Plan?
*
Yes (If yes, please upload IEP Plan)
No (If no, please you're not required to upload an IEP Plan)
Upload file. Copy of IEP Plan
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Dietary Information
Does the child have significant eating issues?
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Does your child currently receive or have received feeding therapy?
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Does your child have any allergies? please specify.
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Does the child have any dietary restrictions?
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Does the child have significant sleep challenges?
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Reason for Referral
What do you hope to gain overall from this assessment for ABA therapy(Please list)
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What are the skills that the child can run independently or without any adult assistant?
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Communicate needs/wants
Socially appropriate eye contact
Appropriate sits in chair upon request
Follows simple directions
Tolerate being told “No”
Sharing/Turn taking
Wants for attention/items when requested without protest
Attends to task/activities for 15 minutes
Transitions between tasks/activities without behaviors
Responds when their name is called
Asks for Help
Imitates actions
Follows routine or schedule
Plays independently for 30 minutes
Communication Skills
How does your child communicate?
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Pushing/Pulling
Uses gestures
Uses facial expressions
Babbling/Sounds
Speaks using single words
Speaks using 1-2 words
Speaks in full sentences
Pictures/PECS
AAC Device
Sign Language
Does the child have poor eye contact during social interactions?
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Please check all the social communication skills that your child can do independently.
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Cooperative playing with others
Requesting information
Expressing own feelings/emotions
Initiating and maintaining conversations
Understanding Sarcasm/humor
Recognizing others’ nonverbal communication
Interested in interacting with peers
Initiates play with others
Maintaining appropriate personal space
Responding to questions
Understanding others perspectives
Interested in social play/leisure activities
Describe the social communication skills changes that you would like to see in the next 6 months.
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Daily Living Skills
Please check all the skills your child can do independently or without any adult assistance.
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Toileting
Brushing teeth
Washing hands
Dressing
Morning routine
Bathing
Please describe daily living skill changes you would like to see in the next 6 months.
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Safety Skills
Does your child engage in any of the following behaviors?
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Careful around hot/sharp objects
Aware of danger stranger
Runs into the street/parking lot
Elope from the house or in the community
Can the child ask for help in case of emergency
Is the client potty trained?
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Yes
No
Other
Do you have any concerns regarding the child's self-help skills?
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Please mention your safety concerns for your child. What changes you would like to see in the next 6 months?
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Please mention concerns while engaging in community activities with your child (e.g., difficulty at restaurants, family vacations. etc).
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Behavior Concerns
Does the child have repetitive body mannerisms? Check any behaviors that your child engages in regarding Restricted, Rigid, and Repetitive behaviors.
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Difficulty with changes in routine/resistance to change
Repetitive patterns of behavior (e.g. turning lights on/off, opening/closing doors, etc.)
Repetitive questions asking
Repetitive motions with objects (e.g bouncing string, spinning wheels)
Restricted/fixated interests
Self-Stimulatory Behaviors
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Finger play
Rocking
Spinning
Vocalizations
Running back and forth
Self Injurious Behaviors
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Self-biting
Headbanging
Scratching self
Hitting self
Disruptive Behaviors
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Tantrums
Biting others
Hitting others
Property Destruction
Kicking others
Elopement
Throwing items
Eating inedible items
Please check and specify sensitivities
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Sounds
Textures
Smells
Touch
Does the child have any sensory needs?
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Does the child have specific interests that are unusual in focus (traffic lights, wheel)?
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Please describe any behavior changes you would like to see in the next 6 months?
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Reinforcer Profile
Please check all the items that your child prefers:
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Toys/game/activities
1:1 Attention
Singing songs
Praise/Positive Comments
Books
Riding bikes
Electronic games
Food or snacks (explain)
Stickers
Other
Parent Training
Parental training is a critical and essential component to make positive gains and to promote your child’s progress. During parent training, your BCBA or Clinical Supervisor will provide you with support and guidance on implementing ABA strategies at home to increase your child’s independence, improve social communication, and address any problem behaviors.
How can we best support you to participate and benefit from parent training sessions?
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Are there any goals that you like us to work on to improve the quality of your family life?
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Is there any additional information that you would like us to know about your child?
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Parent consultation meetings are reserved for Wednesday, Thursday, and Friday weekly. Two meetings in person and 2 via Zoom after 12:00 p.m. Based on your schedule what is the best day that works for you?
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Wednesday
Thursday
Friday
Other
Based on the day that you selected, what is the best time that works for you for a Parent consultation meeting?
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Routine scheduling is a critical component of maintaining appointments each week, including appointments for new clients and follow-ups for existing ones. The schedule is critical for optimal learner success and routine programming. Please select the preferred date and time options listed below for services outside of Learner Social Club.
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Monday 8-12
Monday 12-4
Tuesday 8-12
Tuesday 12-4
Wednesday 8-12
Wednesday 12-4
Thursday 8-12
Thursday 12-4
Friday 8-12
Friday 12-4
Other; Approved Custom Schedule
Based on the selection of "other", what is the custom schedule that was approved and discussed with the BCBA?
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Intake Acknowledgement
I hereby certify that, to the best of my knowledge, the provided information is true and accurate
Date
*
-
Month
-
Day
Year
Date
Parent/Guardian
*
First Name
Last Name
Parent/Guardian Initials
*
*First initial of first name/Last initial of last name
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