Today’s Date:
GERNAL INFORMATION
Name of Person Completing this Form:
Relationship to Child/Adolescent:
Legal Name of Child/Adolescent:
Child/Adolescent’s Date of Birth:
Age:
How did you hear of our ABA agency?
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian 1 Name (First and Last Name):
Parent/Guardian 2 Name (First and Last Name):
Home Address:
Home Telephone:
Parent/Guardian 1 Employer Cell Phone
Parent/Guardian 1 Employer Email
Parent/Guardian 2 Employer Cell Phone
Parent/Guardian 2 Employer Email
MEDICAL INFORMATION
Name of Physician:
Physician Address:
Physician Phone Number:
Child/Adolescent’s Current Height
ft
in
Weight
lbs
Which hand does your child/adolescent show dominance?
If yes, please explain below.
Please also provide the following:
Known Medical Conditions
Dates and Providers of Previous Treatment
Current Treating Clinicians
Current Therapeutic Interventions and Responses
List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child/adolescent has had.
If yes, please explain below and if there are any treatments currently being used for correction.
If yes, please explain below and if there are any treatments currently being used for correction.
If yes, please describe the types of seizures and current treatment.
If yes, please provide the following information:
Name of Medication
Amount
How often is the medication taken?
When is the medication taken?
Please state any reactions or side effects your child/adolescent experiences from the medication.
If yes, please describe, including any adverse reactions:
If yes, please describe, including any adverse reactions and if any epi pen is needed
If yes, please provide the following information:
Diagnosis
Diagnosing Physician
Date Diagnosed
Diagnosis Code
Please note that the diagnosis information is required for insurance coverage. By having this information, it assists us when speaking with your insurance company to get authorization for services and providing you with invoices for reimbursement through insurance.
INSURANCE INFORMATION
Name of Insurance Company
Name of Policy Holder
Social Security #
Date of Birth
Insurance Address
Phone Number:
Member ID
Group ID
Please provide us with a copy of the front and back of your insurance card if you are going to be seeking reimbursement for services through your insurance company.
CURRENT/PREVIOUS THERAPY PROVIDER INFORMATION
Please provide us with information regarding the following types of current or previous therapy providers and copies of any recent evaluations that indicate dates of previous treatment and therapeutic interventions and responses.
Name of Behavioral Provider
Provider Address:
Provider Phone Number:
Email
Name of Speech Therapy Provider:
Provider Address:
Provider Phone Number:
Email
Name of Occupational Therapy Provider:
Provider Address
Provider Phone Number
Email
Name of Physical Therapy Provider:
Provider Address:
Provider Phone Number:
Email
Name of Psychiatric Provider:
Provider Address:
Provider Phone Number
Email
Name of Other Provider:
Provider Address:
Provider Phone Number:
Email
EDUCATIONAL HISTORYPlease list all schools your child/adolescent has attended in order starting with the most current school.
Name of School
School System
Year(s)
Grade
Special Education Services
Please provide us with copies of any reports from evaluations that you may have, as well as a copy of the current 504 plan or IEP
FAMILY BACKGROUND
If yes, which parent/guardian and for how long?
Who has legal custody?
Preferred language
Is it full or joint custody?
Name
Age
Relationship
School &Grade
Name
Age
Relationship
School &Grade
Name
Age
Relationship
School &Grade
PSYCHOLOGICAL HISTORYPlease indicate below whether or not there is a history of the following in your immediate family or in either biological parent’s extended family.
Please provide us with any other information on the psychological history that you feel would be helpful to us in understanding your child/adolescent.
BIRTH AND DEVELOPMENTAL HISTORY
What was your child/adolescent’s birth weight? (lbs)
What was your child/adolescent’s birth weight? (oz)
CURRENT BEHAVIORAL CONCERNS
Please state your goals for your child/adolescent while engaging in a behavioral program.
DISCIPLINE INFORMATION Please rate what percentage of discipline is handled by each of the following
Parent/Guardian 1: %
Relationship to Child/Adolescent
Parent/Guardian 2: %
Relationship to Child/Adolescent
Please state your goals for your child/adolescent while engaging in a behavioral program.
What is typically used for disciplining your child/adolescent (e.g., timeout, assigning chores, physical/corporal punishment, etc.)?
Please describe
Please describe
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