Child Intake Form

ABA STEPS, LLC
908.858.0858

Child Intake Form

Client Name

DOB

( M / F )

Address

Parent / Guardian Name(s)

Phone

Email address

Reason for Referral

Medical History

Dx / Code

Age at Dx

Diagnosing Physician

Phone #

Other Dx/ Disability

Current Primary Physician

Address

Consent to consult with above named Physicians? :

Yes No

Insurance Information

Primary Insurance and ID #

Policy Holder Name

DOB

Secondary Insurance ( if any)

Medications

Medications: ( list all)

Also include purpose and dosage

Allergies?

Has your child ever been hospitalized for medical or psychiatric reasons?

Yes No

Reason

Date(s):

Facility

Health challenges of immediate family members

Does anyone in your family experience mental health issues such as depression/ anxiety or other emotional difficulties?

Family Information

Siblings

Age(s)

Pets

Disposition

Friendly Aggressive

Eating /Sleeping Habits of Child

Likes/ Dislikes

Behavior

Has your child ever

Tried to hurt others or animals?

Self injured?

Displayed concerning behavior?

Display disregard for safety?

Displayed Aggression ?

Frequency and Severity (please describe what this looks like ):

Triggers?

How do you respond to this behavior?

Talked about or attempted suicide?

Does your child display sterotypic ( stimming) behavior?

Functioning

Describe your child’s communication skills

Does your child attend outside Speech or Occupational Therapy?

School

What grade/ program/ class setting does your child attend?

Does your child have an IEP?

What are your child’s favorite activities?

Least favorite?

Favorite foods

Favorite snacks

Level of physical activity

Low Moderate High

How much time PER DAY does your child spend on a phone/ watching TV/ playing video games?

Family Availaility

It is strongly suggested that your child be available for the majority of time they are not in school to optimize the benefits of home- based ABA therapy.

List weekly availability

Please list your therapy goals for your child

Liability Waiver

I hereby waive and release ABA STEPS LLC and its associates, directors, employees, and vendors from any and all claims for loss, injury, or damage. I further agree to indemnify and hold harmless ABA STEPS from any and al claims arising from my child's participation in any ABA STEPS related activity. This agreement shall remain in effect for the duration of participation by my child/family in ABA STEPS related therapy/ Activities. I also grant ABA STEPS and its associates permission to provide emergency medical care in the event of a medical emergency.

I have been informed that I am financially responsisble for all services which may not be covered by my insurance plan. I agree to accept all financial responsibility for all costs associated with services provided by ABA STEPS LLC.

Parent/Guardian E-Signature

Date

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