Behavioral Memory Coaching Intake
Patient Information
Name
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First Name
Last Name
Date of Birth
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-
Month
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Day
Year
Date
Contact Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person
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First Name
Last Name
Emergency Contact Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
1. Behavioral Concerns
Concerns (check all that apply)
Rows
Yes
Details of Condition
Wandering or exit-seeking
Verbal aggression or yelling
Physical aggression
Refusal of care or tasks
Sundowning (late-day confusion)
Repetitive speech or questions
Disrobing or inappropriate behavior
Mood swings or emotional distress
Hallucinations or delusions
2. Known Triggers & Patterns
Please describe any known triggers (e.g., noise, change in routine):
Are there certain times of day when behaviors increase?
Any patterns or situations that help reduce behaviors?
3. Current Behavior Support Strategies
Rows
Yes
Verbal redirection
Distraction with activity or object
Sensory support (music, fidget item)
Routine-based support
Environmental modifications
Medical interventions
Other (please describe below)
Describe any other strategies or responses used:
4. Communication Abilities
Select the best option
*
Verbal - full sentences
Verbal - short responses
Non-verbal - gestures or facial expressions
Uses assistive communication tools
Difficulty understanding or following directions
Please add any context around communication abilities
5. Coaching Goals & Priorities
Check top priorities
Rows
Yes
Notes (optional)
Reduce frequency of challenging behaviors
Increase ability to self-soothe or redirect
Improve engagement in meaningful activities
Promote safe environment
Support caregiver response and understanding
Other (please explain)
Please add any context around goals & priorities
5. What time of day is best for focus and participation?
*
Morning
Midday
Afternoon
Variable
6. Family involvement: Would you like to receive progress updates or participate in sessions?
*
Yes, regularly
Occasionally
No, thank you
7. Preferred contact method
*
Phone
Email
In-person
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