Be Exceptional Support Together Intake Form

Be Exceptional Support Together Intake Form

Any information provided below are confidential and will not be shared with any other party.
Date of Intake:______________________________
Type of Client

Child (Under 18)Adult (18 and Over)
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Email
example@example.com
Cell Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact

Emergency Contact Information
Name

First NameLast Name
Relationship to Client
Phone Number
Email
Primary Caregiver Information(if Applicable)
Name
Relationship to Client
Phone Number
Email
Reason for Seeking Services

Please briefly describe the main reason(s) for seeking B.E.S.T
Diagnosis Information
Primary Diagnosis
Secondary Diagnosis (if applicable):
Date of Diagnosis
Diagnosing Professional
Medicaid Number
Communications Skills
Is the Client Verbal?

YesNoLimited speech
Does the client use an alternative communication method?

YesNo
If yes, please specify

Augmentative and Alternative Communication(AAC)Sign Languagepicture Exchange Communication System (PECS)Other
Behavioral and Sensory Needs
Does the client exhibit any challenging behaviors?
If yes, please describe
Does the client have a behavioral intervention plan (BIP)
If yes, please describe