Daylily Family Consulting Initial Intake Form
Complete the below form at least 24 hours before initial meeting day to allow our consultant time to review.
Family Information
Parent/ Guardian #1
*
First Name
Last Name
Parent/ Guardian #2
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Household Size (including all occupants)
*
Please Select
2
3
4
5
6
7
8
9
10+
Children's Names and Ages (Include month/ year of birth)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Email
*
example@example.com
What brought you to Daylily?
Answer the following questions including all children
What specific behaviors are causing the most stress or disruption right now? Please describe exactly what they look like.
*
How long has this specific behavior been occurring?
*
On average, how often does this behavior happen?
*
Multiple times an hour/day
Daily
A few times a week
Rarely/Cyclically
How long does an episode typically last when it happens?
On a scale of 1 to 10 (10 being severe safety risk), how would you rate the severity or impact of this behavior?
*
1 (Minimal Impact)
1
2
3
4
5
6
7
8
9
10 (Severe Safety Risk)
10
1 is 1 (Minimal Impact), 10 is 10 (Severe Safety Risk)
Environmental Triggers & Context
When is this behavior most likely to happen? (e.g., specific times of day, during transitions, when a specific request is made)
When is this behavior least likely to happen? (e.g., during preferred tasks, with specific people, during free time)
Who is typically present when the behavior occurs?
Are there any clear environmental triggers? (e.g., loud noises, crowded spaces, being told “no”, a change in the normal routine)
Describe your children’s current sleep patterns and typical daily routine.
Consequence & Action
What usually happens immediately after the behavior occurs? (e.g., access to an item, a break from work, verbal reprimands/attention)
What strategies or discipline techniques have you already tried to address this behavior?
Which of those past attempts seemed to work temporarily, and which made the behavior worse?
What do you think your child(ren) is trying to communicate or achieve through this behavior? (e.g., escaping a task, getting attention, getting an item, sensory relief)
Background, History, & Strengths
Please list any current medical diagnoses, relevant health history, or developmental milestones.
Is the client currently taking any daily medications or supplements? If yes, please list them.
Are they currently receiving other services? (e.g., Speech Therapy, Occupational Therapy, Psychotherapy, IEP at school)
What are the client’s greatest strengths, talents, or favorite activities?
What are their favorite items, toys, treats, or topics?
Goals & Expectations
What are your primary goals for this behavioral consultation?
If you could change just one behavior in the next three months, what would it be?
Are there any specific cultural values, family dynamics, or communication preferences our consultant should keep top of mind?
Submit Intake
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