Therapetuic Consultation

3. Current Service Providers (Residential, Day Support, Job Coaching, Speech, ABA Therapy)

5. Areas of Concern (check and describe all that apply)

Rows	Indicate if they currently engage in this behavior or if they have in the past. Additionally, please indicate how often the behavior happens (hourly, daily, weekly, monthly, etc)
Pica (consuming inedibles, toxic substances)
Rectal digging, feces smearing
Food refusal
Skin picking, pinching, scratching
Head slapping/hitting head with object (e.g., hand to own knee/object to self)
Head banging on hard surfaces
Head banging on soft surfaces (bed(
Refusal to comply with medical or dental care/evaluations
Refusal to comply with hygiene care/routines that impact health and/or social acceptance

Mouthing unsafe objects
Illegal drug use
Elopement (leaving house/clinic/safe area without supervision)
Suicide attempts/illustration - threats to cause harm to self (with ability to follow-through)
Aggression
Compulsive sexual behaviors
Disrobing in public
Verbal aggression (profanity towards others)
Emotional Outbursts (screaming, crying, dropping to the ground, etc)
Property destruction (throwing items, breaking items, kicking items)
Harassment towards others (online, in person)
Other: Please explain below
6. Please describe any additional behaviors, concerns, or challenges you would like addressed
Signature of Individual, Guardian, or Service Coordinator
Should be Empty:

New Client Service Request