AIA Learner Pre-Assessment Form

AIA Learner Pre-Assessment Form

Please complete ALL the questions within the following Intake form to determine the best quality service experience for your child. Your Client Advocate will contact you within 24-72 hours upon completion.
Assigned Arizona Institute for Autism Client Advocate: Jennifer Bonefont
Child Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Parent Guardian Relationship to Child
Primary Email Address
example@example.com
Parent/ Guardian Name

First NameLast Name
Parent Guardian Relationship to Child
Secondary Email Address
example@example.com
Family Life
Are there any current, relevant Legal issues involving the child and /or family, not limited to divorce, custody, and /or guardianship issues?
Sibling/(s)(Names/ages):
Other than parents and siblings, who lives in the home:
List any cultural or spiritual practices that may limit ABA therapy, if any
In Regards to the in-home services, once services starts, the case BCBA will discuss environment and family dynamics, that ensure session effectiveness. Please list questions you may have!
List sIgnificant Pre- and Perinatal Events.
Medical History
What are the Medical diagnoses for your child including Autism, ADHD, and other Learning Disabilities?
Name of Provider who diagnosed the child with Autism?

First NameLast Name
Provider who Diagnosed Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider who Diagnosed Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider who Diagnosed Phone Email
example@example.com
Date of Diagnosis

MonthDayYear
Date
*Upload file. Copy of the current Developmental Diagnosis is Required

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Is the child using any medication(s)? Please list names of medication(s), dosage, and frequency
Is there any family history of medical, developmental, learning, emotional, mental health, or psychiatric difficulties?
Has the child ever received any ABA treatment before? Please mention the name of the facility and weekly hours received.
Has the child a present or past seizure history. Please explain!
Name of Pediatrician Provider

First NameLast Name
Pediatrician Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pediatrician Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pediatrician Provider Email
example@example.com
Name of Developmental Doctor Provider

First NameLast Name
Developmental Doctor Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Developmental Doctor Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Developmental Doctor Provider Email
example@example.com
Does your child receive any additional services including Speech Therapy, Physical Therapy, Occupational Therapy, or ABA Therapy? Please mention the name of the facility and the frequency.
School Information
School Name
Educational Placement (General Education, Special Education, Self-Contained, or others)
Grade
School Time
School Days Attending
Does the child currently have an IEP Plan?
Upload file. Copy of IEP Plan

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Dietary Information
Does the child have significant eating issues?
Does your child currently receive or have received feeding therapy?
Does your child have any allergies? please specify.
Does the child have any dietary restrictions?
Does the child have significant sleep challenges?
Reason for Referral
What do you hope to gain overall from this assessment for ABA therapy(Please list)
What are the skills that the child can run independently or without any adult assistant?
Communication Skills
How does your child communicate?
Does the child have poor eye contact during social interactions?
Please check all the social communication skills that your child can do independently.
Describe the social communication skills changes that you would like to see in the next 6 months.
Daily Living Skills
Please check all the skills your child can do independently or without any adult assistance.
Please describe daily living skill changes you would like to see in the next 6 months.
Safety Skills
Does your child engage in any of the following behaviors?
Is the client potty trained?

Other
Do you have any concerns regarding the child's self-help skills?
Please mention your safety concerns for your child. What changes you would like to see in the next 6 months?
Please mention concerns while engaging in community activities with your child (e.g., difficulty at restaurants, family vacations. etc).
Behavior Concerns
Does the child have repetitive body mannerisms? Check any behaviors that your child engages in regarding Restricted, Rigid, and Repetitive behaviors.
Self-Stimulatory Behaviors
Self Injurious Behaviors
Disruptive Behaviors
Please check and specify sensitivities
Does the child have any sensory needs?
Does the child have specific interests that are unusual in focus (traffic lights, wheel)?
Please describe any behavior changes you would like to see in the next 6 months?
Reinforcer Profile
Please check all the items that your child prefers:

Other
Parent Training

Parental training is a critical and essential component to make positive gains and to promote your child’s progress. During parent training, your BCBA or Clinical Supervisor will provide you with support and guidance on implementing ABA strategies at home to increase your child’s independence, improve social communication, and address any problem behaviors.
How can we best support you to participate and benefit from parent training sessions?
Are there any goals that you like us to work on to improve the quality of your family life?
Is there any additional information that you would like us to know about your child?
Parent consultation meetings are reserved for Wednesday, Thursday, and Friday weekly. Two meetings in person and 2 via Zoom after 12:00 p.m. Based on your schedule what is the best day that works for you?
Based on the day that you selected, what is the best time that works for you for a Parent consultation meeting?
Routine scheduling is a critical component of maintaining appointments each week, including appointments for new clients and follow-ups for existing ones. The schedule is critical for optimal learner success and routine programming. Please select the preferred date and time options listed below for services outside of Learner Social Club.
Based on the selection of "other", what is the custom schedule that was approved and discussed with the BCBA?
Intake Acknowledgement

I hereby certify that, to the best of my knowledge, the provided information is true and accurate
Date

MonthDayYear
Date
Parent/Guardian

First NameLast Name
Parent/Guardian Initials
*First initial of first name/Last initial of last name
Should be Empty:

AIA Learner Pre-Assessment Form

Assigned Arizona Institute for Autism Client Advocate: Jennifer Bonefont

Family Life

Medical History

School Information

Dietary Information

Reason for Referral

Communication Skills

Daily Living Skills

Safety Skills

Behavior Concerns

Reinforcer Profile

Parent Training

Intake Acknowledgement