Family Medical Behavioral Information
Parent / Guardian Name
Relationship to Client:
Parent
Guardian
Other
Are you authorized to consent for this individual’s healthcare?
Yes
No
Client Information
Client Name
Client Date of Birth
/
Month
/
Day
Year
Date
Client Gender
Client Address
Client Primary Language
Client Secondary Language
Primary Caretakers: (Please list the family members, teachers, or other individuals who care for your loved one on a regular basis)
Rows
Name
Relation to Client
Phone Number
Caretaker 1
Caretaker 2
Caretaker 3
Caretaker 4
Parent / Caregiver Status
Married
Divorced
Separated
Single
Legal Guardian
Other
If Divorced/Separated, who is responsible for making medical and behavioral health decisions for the client?
Joint
Sole
If sole custody, specify which parent:
Are both parents aware ABA services are being sought? If No, please list reason why.
Yes
No
If no, please list reason:
Household 1
Household 1 Address
Percentage of time client spends in household 1
Household 1 Family Members
Rows
Name
Age
Gender
Relationship to Client
Family Member
Family Member
Family Member
Family Member
Family Member
Household 2
Household 2 Address
Percentage of time client spends in household 2
Household 2 Family Members
Rows
Name
Age
Gender
Relationship to Client
Family Member
Family Member
Family Member
Family Member
Family Member
Educational History
Attended/Participated in Early Intervention Program (before age 3)
Yes
No
Currently
Name of Early Intervention Program
Attended pre-school?
Yes
No
Currently
Name of school:
In any special education class?
Yes
No
Currently
Name of class/program?
Repeated grade?
Yes
No
Currently
Grade held:
Ever suspended / expelled?
Yes
No
Currently
Reason:
Speech Therapy?
Yes
No
Currently
Speech Minutes per month
Occupational Therapy?
Yes
No
Currently
Occupational Therapy Minutes per month
Physical Therapy?
Yes
No
Currently
Physical Therapy Minutes per month
Adaptive PE?
Yes
No
Currently
Adaptive PE Minutes per month
Individual Intervention Services
Yes
No
Currently
IIS Minutes per month
Current Daycare/School Schedule
Current Daycare/School
Teacher’s Name
School Address
City
State
Zip code
District
School Phone
Format: (000) 000-0000.
School E-mail
example@example.com
Community Based Services
Please list previous and current therapies/programs/activities the client has attended.
Rows
Service Type
Provider
Started
Ended
Intensity
Days of Service
Therapy/Program 1
Therapy/Program 2
Therapy/Program 3
Therapy/Program 4
Therapy/Program 5
Therapy/Program 6
Medical History
DIAGNOSES:
Please list any medical, psychological, psychiatric diagnoses that your loved one has received, including any previous or current infectious diseases.
*The following must be formal medical diagnosis not simply characteristics with diagnosing physician.
Rows
Diagnosis
Diagnosis Date
Physician
Allergies:
Rows
Allergic To:
Notes
Allergy 1
Allergy 2
Allergy 3
Allergy 4
Please describe any complications that occurred during mother's pregnancy or during client's birth.
Length of pregnancy (in weeks)
Weight at birth
Please describe any major medical problems client has experienced.
Is the client currently under a doctor’s care for any medical condition?
Yes
No
If yes, please describe condition
Physician
Physican's Office Name:
Physician Phone
Format: (000) 000-0000.
Physician Address
Please list any current medications below:
Rows
Medication
Dosage
Physician
Purpose
Side Effects
Sociological Information
About how many hours of sleep does the client get each night?
Does the client sleep through the night?
Yes
No
Does the client have any eating habits that may affect their behavior?
Yes
No
If yes, please describe eating habits that may affect behavior:
List any significant changes within the family and/or family situation within your loved one’s life. Also include any traumatic events experiences or witnessed by the client.
Describe how these changes or events have affected the client.
Is the client currently experiencing any homicidal or suicidal ideations?
Yes
No
Has the client been a victim of any kind of abuse?
Yes
No
Has the client been a perpetrator of any kind of abuse?
Yes
No
If yes to either, please describe below
Pertinent Family History
Is there a family history of any of the following? Please check all that apply that could affect the client's behavior, treatment implementation, and/or the participation of team members (e.g., sibling/caregiver’s psychological diagnoses, medical conditions, medications/treatments, substance abuse, etc.)
Hearing Loss:
Speech Deficits/Delays
Educational Barriers
Attention Disorders
Seizure Disorders
Drug Use
Delayed Motor Development
Mental Illness
Other
Cultural Considerations
Please describe below important cultural practices, rituals, traditions or beliefs that you believe are important for us to be aware of prior to initiating a therapeutic relationship.
Client Strengths and Interests
Please indicate anything that the clinicians should know when working with him/her.
Strengths
Preferences (favorite activities, songs, toys, topics, sensory, etc.)
Other Information
Concerns
Please explain the reason for seeking ABA services
Family Preferences:
Please list the top three areas/goals you would like to see improvement for the client in next 6 months
Goal / Skill Area 1
Goal / Skill Area 2
Goal / Skill Area 3
Child's Behaviors:
Please check all that most closely describe your child:
My child engages in Self-Stimulatory behaviors:
Finger play
Sniffing / Smelling objects
Rocking
Spinning
Vocalizations
My child engages in Self-Injurious behaviors:
Self-Biting
Scratching Self
Head Banging
Self-Hitting
My child engages in Aggressive/Highly Disruptive behaviors:
Tantrums
Pinching Others
Biting Others
Hitting Others
Self-Care:
Please check all that most closely describe your child:
Toileting: My child...
Is in diapers at all times
Is in diapers but taken to bathroom
Is urine-trained
Is bowel-trained
Is night-time trained
Eating: My child...
Exhibits strong food preferences
Exhibits strong food aversions
Eats well balanced diet
Language: My child...
Speaks in full sentences
Speaks in short phrases
Uses single words
Uses some sign language
Uses gestures (pointing/pulling hand)
Does not use words, signs or gestures
Documentation
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Parent/Caregiver Signature
Date
/
Month
/
Day
Year
Date
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