DLL Intake Form

DLL Intake Form

Please complete this form in its entirety. Your responses guide assessment planning and implementation.
Child and Parent/Guardian Information
Child’s Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name(s)
Preferred Method of Contact
Primary Language(s) Spoken in Home
Parent/Guardian Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Home Address:
Emergency and Referral Information
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring or Primary Care Physician Name

First NameMiddle NameLast Name
Physician Practice / Clinic Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Permission to Contact Referring Physician
Diagnostic and Medical History
Has your child ever been diagnosed with any developmental, learning, behavioral, or medical conditions?
Please list all diagnoses and approximate dates of diagnosis
Has your child received ABA Therapy in the past?
If yes, where and how often?
Does your child attend additional therapies (such as speech, OT, PT, Play, Feeding, etc.)
If yes, list all therapy providers and how often your child attends.
Does your child attend school?
Name of School and Grade Level
Is your child currently taking any medications (prescribed or over-the-counter)? *Over-the-counter includes Miralax, Benadryl, melatonin, etc.
List current medications, dosage, and frequency
Does your child have any known allergies?
Please list all allergies and reactions
Has your child had any major illnesses, surgeries, or hospitalizations?
Please describe major illnesses, surgeries, or hospitalizations
Does your child have any history of seizures or other neurological concerns?
Please describe seizure history or neurological concerns
Has your child had any hearing, vision, or other sensory concerns?
Please describe hearing, vision, or other sensory concerns
Behavior
Behavioral concerns

Other
Antecedents (Happen prior to behavior)

Other
Consequences

Other
Behavior description- What does the behavior of concern look like?
Frequency (How often does the unwanted behavior occur?)
Duration (How long does the behavior last?)
Intensity- Rate the behavior(s) of concern as mild, moderate, or intense
Setting events (List events that may contribute to your child's behavior such as sleeplessness, constipation, chronic illness, etc)
What helps calm the behavior?
Other behaviors or concerns
Communication, Social Skills, and Daily Living Skills
Communication methods used

Other
Communication Challenges Displayed:
Follows one-step directions
Follows two-step directions
Answers yes/no questions
Answers WH-questions
Additional communication concerns
Communication Strengths
Social interaction skills completed independently

Other
Social skills strengths
Social skills concerns
Daily living skills achieved independently

Other
Needs help with self-care tasks
Safety awareness
Where is your child with toilet training? (it's ok if you haven't started yet or explain how toilet training has gone thus far)
How does your child handle changes in routine or unexpected events?
List an ABA treatment concerns:
Primary ABA Goals- Tell us what your primary short term goals are for your child
What would success look like? List long term goals for your child.
Target Areas (Check the areas you would like ABA to address)

Other
List your child's favorite/preferred things:
Do you consent to ABA services?
Do you consent to indirect communication with school or other providers?
Do you consent to sharing treatment updates with authorized caregivers?
Do you authorize use of electronic signatures and records?
Do you acknowledge receipt of informed consent information? (Attached in a separate document)
Do you acknowledge the privacy practices notice?
Primary Insurance Provider
Member ID
Group ID
Policy Holder Name
Policy Holder Relationship to Client
Coverage Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Coverage End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you authorize the clinic to verify benefits with the insurer?
Do you authorize the clinic to submit claims on your behalf?
Client or Parent/Guardian Signature
Printed Name of Signatory
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Front of Insurance Card

Cancelof
Upload Back of Insurance Card

Cancelof
Additional Notes About Goals or Insurance
Should be Empty:

DLL Intake Form

Child and Parent/Guardian Information

Emergency and Referral Information

Diagnostic and Medical History

Behavior

Communication, Social Skills, and Daily Living Skills