(Child) Client Intake Form for Behavioral Consulting 1.23.24

BEHAVIORAL HEALTH NETWORK

DR. JOSEPH SCHEMBRI, JR.

496 MAIN STREET, 2ND FLOOR

MEDFIELD, MA 02052

Phone: 1-508-246-6493

e-mail: bhn@behavioralhealthnetwork.org or

bschembri@behavioralhealthnetwork.org
CHILD IN-TAKE FORM

All information given is strictly confidential. At no given point is information disclosed or shared without client’s written consent. You may skip any questions you do not feel comfortable answering.
Name

First NameLast Name
Insurance Information

Kindly fill in your insurance information on this form and upload a photo of the back and front of your insurance card below. If you have any questions, please contact bschembri@behavioralhealthnetwork.org.
Name of Current Insurance Company
"Please upload a photo of the front side of your insurance card"

Upload File

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"Please upload a photo of the back side of your insurance card"

Upload File

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Member IDGroup #DeductibleCoPay
Secondary Insurance Company/Name
Member IDGroup #DeductibleCoPay
Demographic Information
Legal Name of Child

First NameMiddle NameLast Name
Today's Date

MonthDayYear
Gender

Other
Child's Age
Grade
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian

First NameLast Name
Occupation
Phone Number
Format: (000) 000-0000.
E-mail
Parent/Gaurdian

First NameLast Name
Occupation
Phone Number
Format: (000) 000-0000.
E-mail
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Educational History
List all schools your child has attended.
School Name
Year(s) Attended
Grade(s)
School Name
Year(s) Attended
Grade(s)
School Name
Year(s) Attended
Grade(s)
List any other schools attended here. Include school name and years attended.
Does your child have an IEP (Individualized Education Program)?
Date of last IEP meeting

MonthDayYear
Household Information
List everyone who resides in the child's household, including ages.
How would you describe your parenting style?
Medical Information
Is your child taking any daily medication(s) or supplements?
Medication & dosage
When began
Medication & dosage
When began
Medication & dosage
When began
Describe your child's typical day/routine (e.g., 7:00 wake up, 7:30 breakfast, etc.). List specific wake up, nap, and bed times.
Problems and Solutions
What are some of your child's strengths?
What does your child like to do in his/her free time?
Provide a general overview of the behaviors of concern.
Are there times of the day when the behavior is more likely to occur?
Are there specific activities when the behavior is more likely to occur?
How frequently is the behavior occuring?
Are there circumstances that occur on some days and not others that make behavior more likely to occur?
What have you tried already to try to manage the behavior?

Please rate how likely you are to use each of the strategies listed.

Rows	Highly Unlikely	Unlikely	Neutral	Likely	Very Likely
Let situation go
Take away a privilege
Asking an additional chore
Take away a tangible/object
Send to room
Reason with child
Send to time out

What is your main goal for this consultation?
Date

MonthDayYear
Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Browse Files

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Should be Empty:

Insurance Information

Demographic Information

Educational History

Household Information

Medical Information

Problems and Solutions