Family Intake Packet Form

Family Intake Packet Form

Gather essential information to understand your child's needs and preferences. If a section does not apply to your child put N/A and continue with the form.
Child's Behavioral Information
Child's Full Name

First NameLast Name
Known Behavioral Concerns
Triggers
Calming Strategies
Reinforcers/Rewards
Aggressive Behaviors
Self-Injurious Behaviors
Elopement/Wandering Risk
Property Destruction
Safety Concerns
Parent/Guardian Full Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diagnosis/Type of Intellectual Disability
Child's Communication Information
Please describe your child's communication style and preferred methods (e.g., verbal, non-verbal, sign language, communication device).
Does your child have any medical conditions or allergies?
Are there any behavioral triggers or calming strategies we should know about?
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else we should know to provide the best care for your child?
Should be Empty:

Child's Behavioral Information