Step 1 of 7 14% Location Requested: Winchester114 South Maple StreetWinchester, KY 40391 Lexington3257 LochNess DriveLexington, KY 40517 Child's NameGender: Male Female Non-binary Child's Date of Birth MM slash DD slash YYYY Child's AddressCity/State/ZipHome PhoneMomMom's NameMom's Date of Birth MM slash DD slash YYYY OccupationEmployerWork PhoneCell PhoneEmail Address DadDad's NameDad's Date of Birth MM slash DD slash YYYY OccupationEmployerWork PhoneCell PhoneEmail Address Who does the child live with (please include siblings if applicable)?How did you hear about us? Family Friend Doctor Other Other:PhysicianPhysician Referred ByAddressCity/State/ZipPhoneReason for ReferralPrimary Care PhysicianIf different from referring physicianAddressCity/State/ZipPhoneInsurance InformationPrimary InsuranceClaims AddressCustomer Service Phone NumberFaxInsured's NameID/Policy #Group #Secondary InsuranceClaims AddressCustomer Service Phone NumberFaxInsured's NameID/Policy #Group # Parent/Guardian Questionnaire Developmental HistoryPerinatal History – Please describe any complications before, during, and after birthApproximate Age of Developmental Milestones:RollingSittingCrawlingWalkingFirst WordApproximate # of utterances/ partial wds / wds:Please note the current status of the followingMobilitySpeechDaily Skills (dressing, feeding, toileting, etc)School PerformanceBehaviorOther Medical HistoryHas your child ever received a medical diagnosis? Yes No If yes, who diagnosed the child, what is the diagnosis, and when did child receive diagnosis?Add more rows as needed.DiagnosisDateDoctor Add RemovePrevious hospitalizations/surgeries/illnessesAdd more rows as needed.TypeDateDoctor Add RemovePrevious or Present Therapies (if any)Previous or Present Schooling (if any)Current MedicationsAdd more rows as needed.MedicationDosagePurposePrescribed By Add RemoveAllergies: What Are You Looking For From Our ABA Program? What is your goal for ABA services? Focused intervention (approximately 10-20 hours/wk of treatment) Comprehensive program to address the diagnosis of autism (language, social isolation / repetitive behavior) (25 – 40 hours/wk of treatment) Behavior or specific issue(s) you would like addressedGoals for interventions Behavior Intake QuestionnaireChild's NameDate of Birth MM slash DD slash YYYY Name of Person Completing QuestionnaireRelationship to the Child Child Diagnosis(es) when diagnosed (month/year) and doctor who gave diagnosis:Add more rows as needed.DiagnosisDateDoctor Add RemoveDoes your child attend other therapies at this time? Yes No If Yes, please list below:Add more rows as needed.TherapyLocationTherapist Add RemoveDoes your child have any medical conditions (asthma, allergies, seizures, etc.)? If so, please describe:Does your child have any medication allergies?What are your current concerns? communication dressing feeding/eating toilet training social skills coping skills safety skills independence skills self injurious behaviors physical aggression verbal aggression non compliance PICA flopping/dropping elopement tantrum other Other?Describe behaviors of concern below: (behaviors you would like to decrease/eliminate)Add more rows as needed. Behavior: Hitting What does it look like? Smacking on the arm with an open hand How often does it happen? Every night at homework time How long does it last? About 2 minutes Why do you think it happens? Doesn’t want to do the work What happens after? Didn’t finish homework, went to watch tv BehaviorWhat does it look like?How often does it happen?How long does it last?What happens after? Add RemoveList your child’s most preferred things (food, people, movies, shows, games, etc) that can/may be used IN SESSIONS as rewards/reinforcersHow does your child communicate? Verbally Pictures Pulling Sign iPad/Device Can they communicate wants and needs without behaviors? Yes No Can they accept no/redirect without behaviors? Yes No Can they follow directions with 2 or less verbal prompts? Yes No Can they imitate physical models (ie. Do this… watch me….) Yes No Can they complete age appropriate hygienic tasks independently? Yes No Can they dress themselves independently? Yes No Does your child have age appropriate chores/responsibilities at home? Yes No Does your child understand and follow basic safety rules?(ie. Look both ways, don’t run in the parking lots, stay with mom/dad, etc.) Yes No Does your child make eye contact? Yes No Can your child share preferred items? Yes No Is your child a picky eater? Yes No If so, name 3 foods your child WILLINGLY eats:If so name 3 foods you WANT your child to eat:Will your child eat: fruits vegetables meats dairy breads/pastas sweets/candy Types of fruit your child will eatTypes of vegetables your child will eatTypes of meat your child will eatTypes of dairy your child will eatTypes of breads/pastas your child will eatTypes of sweets/candy your child will eatWill your child drink: water juice milk soda other Types of water your child will drinkTypes of juice your child will drinkTypes of milk your child will drinkTypes of soda your child will drinkOther beverages your child will drinkDoes your child have any food allergies? Yes No Please list your child's food allergiesDoes child sit and eat dinner? Yes No Does your child graze throughout the day? Yes No Does your child sleep through the night? Yes No If NO, please describe your child’s sleep habits:Is your child toilet trained? Yes No Is your child able to sit WITHOUT engaging in behaviors while EATING for: less than 2 min 2 min 5 min 10 min 15 min 20 min 20 min + Is your child able to sit WITHOUT engaging in behaviors while WORKING/TASK ACTIVITY for:(ie. Homework) less than 2 min 2 min 5 min 10 min 15 min 20 min 20 min + Please give an example of a WORKING/TASK ACTIVITYIs your child able to sit WITHOUT engaging in behaviors while PREFERRED ACTIVITY for:ie, game, tablet less than 2 min 2 min 5 min 10 min 15 min 20 min 20 min + Please give an example of a PREFERRED ACTIVITYWhat things would you most like to see increased or improved? (ie. Sharing, requesting, toilet training, waiting, dressing self, etc.) Please list a few below.Add up to 10 rows as needed Add RemoveAre there any other topics that you would like to discuss or address that were not on this form? If so, please describe below: Thank you for taking the time to complete this intake application for ABA Therapy. This information will be reviewed and further questions will be asked if necessary to determine the most appropriate service path for your child. Please leave contact information below: NamePhone NumberEmail Address Preferred form of contact Call Text Email PhoneThis field is for validation purposes and should be left unchanged. Δ
