Getting Started Download and Fill Out Form PATIENT INFORMATION Male Female (Gender assigned at birth) Client Name First Last Parent's Name First Last Insurance Type Subscriber's ID Street Address Apartment Number City State ZipDate of Birth MM slash DD slash YYYY PhoneEmail DIAGNOSTIC INFORMATIONDiagnostic Practitioner Name Primary Diagnosis Code Initial Evaluation Date MM slash DD slash YYYY Most Recent Evaluation Date MM slash DD slash YYYY SCHOOL & THERAPY HISTORYSchool Previous ABA Therapy Speech Therapy Occupational Therapy Physical Therapy Other: What is the primary language spoken in the home? Describe their independence with toileting.Please SelectIndependent with Urination & BMIndependent with Urination onlyFew RemindersPrompted on a scheduleNoneSleep Difficulties? Eating Difficulties? Do they have any allergies or food restrictions (gluten free, vegetarian)? Are they currently taking any medication? If so, what is the medication & dosage taken? What types of challenging behaviors does your child display? Check all that apply. SIB Physical Aggression Property Destruction Elopement Ritualized/Routine Behavior Public Urination/Defection Uncooperative Behaviors Vocal Disruption/Aggression Stereotypy Mouthing Disrobing Inappropriate Sexual Behaviors Other How often does problem behavior occur (hourly, daily, weekly) and what typically causes it to occur (when told no, when asked to do something)?Receptive Communication: 1) How does your child typically respond to nonverbal cues, such as gestures or facial expressions? 2) Can you share an example of a 1-2 step instruction you might give to your child, and how well do they usually follow it? 3) When you ask your child to do something specific, like pick up their toys, how do they typically respond? Do they seem to understand and follow through?Expressive Communication: 1) How does your child typically communicate their needs and wants? 2) Can your child express themselves verbally, or do they use alternative communication methods? 3) Are there specific challenges or strengths related to your child's communication?Social Skills: 1) How does your child engage with peers or siblings in social situations? 2) Does your child initiate play activities or imitate others? 3) Are there specific social situations that your child finds challenging or particularly enjoyable?Play: 1) Describe how your child engages in play activities. 2) Are there specific types of play or activities that your child enjoys or finds challenging?Daily Living Skills: 1) How independent is your child in activities such as dressing, grooming, and feeding themselves? 2) Are there specific daily living skills that your child struggles with or excels at?Task Completion: 1) How does your child approach tasks and assignments at home or school? 2) Are there specific challenges your child faces when it comes to completing tasks?Self-Help Skills: 1) How independent is your child in tasks like tying shoelaces, using utensils, or managing personal belongings? 2) Are there self-help skills your child is working on mastering?Emotional Regulation: 1) How does your child typically express and manage their emotions? 2) Are there specific situations or triggers that impact your child's emotional regulation?Adaptive Skills: 1) How well does your child adapt to changes in routine or environment? 2) How does your child handle transitions between different activities or settings? 3) Are there specific adaptive skills, such as using coping skill, independence with routines or learning to problem- solving, that you'd like us to address?What specific goals or skills do you want your child to achieve in the next 3-6 months? What about a year from now?Active engagement from parents is crucial for the success of our ABA programs. Families must engage in Family Guidance Training, collaborating with our behavior analysts or therapists. We suggest a commitment of at least 2 hours per month, with a minimum of 1 hour. How frequently can you participate each month? Are you able to join over the phone, in person, online? 1 hour per month 2 hours per month 3 hours per month In Person-Office Online-Video Meeting Phone Call POTENTIAL FAMILY GUIDANCE GOALSABA Goal 1: ABA Goal 2: ABA Goal 3: NameThis field is for validation purposes and should be left unchanged.
