Behavior Intake Form

Please correct the errors described below.

Pregnancy: If applicable, please write in 'Yes' and provide details

Labor/Delivery: if applicable, write in 'Yes' and describe

Extended Family Psychological History: If applicable, write 'Yes' and describe who in the family had the condition

Developmental Milestones: write in age and comments

Friendship: if applicable, write in 'Yes' and provide comments

Education

Childhood Health: If applicable, write 'Yes' and explain

Developmental Team: For each specialist, list name, dates seen and findings

Issues/Problems: If applicable write in the age and grade and explain

Language Skills Assessment: If applicable, write 'Yes' and explain

Social Skills Assessment: if applicable, write 'Yes' and provide comments.

Academic Skills Assessment: If applicable, write 'Yes' and provide comments

Gross Motor Skills: If applicable, write 'Yes' and provide comments

Self Help Skills: if applicable, write 'Yes' and provide comments

Fine Motor Skills: If applicable, write 'Yes' and provide comments

Discipline: Please write frequency and method if applicable

General Information

Please list the things that reinforce your child

Treatment History

Special Education Classroom

Speech Therapy:

Occupational Therapy

Physical Therapy

Other ABA Program

Other:

Self Stimulatory Behavior

Vocal (repeating vocalizations, words or phrases)

Preoccupations with items, topics, etc.

Repetitive motor mannerisms (hand flapping, spinning items, lining up objects, etc.)

Routine behaviors (insisting on the same cup, same route in the car)

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