Behavior Intake Form

Child’s Last Name

Child’s First Name

Middle Name

Child’s Gender

Child’s Date of Birth

Child’s Age

Child’s Current Address

Primary Family Email

Mother’s Full Name

Mother’s Occupation

Mother’s Place of Employment

Mother’s Cell Number

Mother’s Work Number

Father’s Full Name

Father’s Occupation

Father’s Place of Employment

Father’s Cell Number

Father’s Work Number

Who does the child live with?

Are parents married or divorced?

If divorced, who has custody?

If divorced, please list stepparents

If divorced, list for how long

List names and ages of all siblings in the home

List names and ages of any other family members in the home

Primary Pediatrician/Doctor’s Name

Doctor’s Phone and Fax

Address Including City and Zip

Child’s Medical Diagnosis and Date

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

Was bed rest recommended

Yes No

Any exposure to alcohol

Yes No

If yes to any of the above, provide details

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

C Section?

Yes No

Breech?

Yes No

Oxygen Assist?

Yes No

Structural Abnormalities (i.e.cleft lip)

Yes No

Birth Weight lbs oz

If yes to any of the above or 'No' to Vaginal delivery, describe:

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

Bipolar Disorder

Yes No

Anxiety Disorders (OCD, Phobias)

Yes No

Mental Retardation

Yes No

Psychosis/Schizophrenia

Yes No

Substance abuse/other Dependency

Yes No

Other mental health concerns?

Yes No

If yes to any of the above or other disorders not listed, please describe:

Developmental Milestones: write in age and comments

Rolled over consistently

Crawled (was crawling phrase brief?)

Walked unassisted

Fed self

Dry through the night for 6+ months

Said first word understood by strangers

Used sentences regularly

Sat up unsupported

Drank from a cup

Was toilet trained during the day for 6+ months

Dressed self

Said two-three word phrases

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

Does your child have problems relating or playing with others?

Fights frequently with playmates?

Prefers playing with younger children?

Has difficulty making friends?

Prefers to play alone?

Is your child the aggressor in group games?

Is your child a follower in group games?

Is your child a leader in group games?

Other

Education

Does your child attend school? Please list name of school

Does your child have a primary teacher? Please list name

Does your teacher have concerns about your child?

Does your child have a favorite class/subject? If so what?

Does your child have a least favorite class/subject? What?

Has your child ever repeated a grade? If so what grade?

Other

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

Has your child been diagnosed with Autism?

Pervasive Developmental Disorder?

Nonverbal Learning Disorder?

Sensory Integration Disorder?

Has your child had any significant falls or injuries?

Has your child ever been hospitalized? Reason:

Does your child have any allergies?

Does your child have any compulsive behaviors?

Has your child had a head injury: occurrence, location on skull?

Any hearing problems? Date of last test:

Any vision problems? Date of last test:

Other

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

Allergist

Audiologist

Speech Pathologist

Gastroenterologist

Neurologist

Nutritionist/Dietitian

Occupational Therapist

Ophthalmologist

Physical Therapist

Psychiatrist

Psychologist

Cardiologist

Other:

List all current medications, dosages, frequency taken and reason

List all allergies to medicine, if reaction is midl or sever and type of reaction

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

Problems with eating?

Socially isolated from peers?

Problems making/keeping friends?

Problems getting to sleep?

Problems controlling temper?

Problems sleeping through night?

Problems waking up?

Fatigue/tiredness during the day?

Soiling?

Nightmares?

Bed wetting?

History of abuse?

Alcohol/drug use/abuse?

School concentration?

Grades dropping?

Sadness or Depression?

Please explain the conditions you checked above

For those items checked above, provide age and comments

For the activities checked above, please provide age and comments

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

Does your child look at books?

Play with cause/effect toys (i.e.: Jack in the Box)?

Complete task completion toys (i.e.: puzzles, beads)?

Play with toys like they are real items?

Play games like ring around the rosy?

Construct items using blocks, Legos?

Play games with rules (i.e.; memory)?

Engage in dress up or role play (i.e. pretending to be a barber?)

Play appropriately on his or her own for up to 5 minutes?

Do you have any concerns regarding your child’s play skills?

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

Does your child respond to his or her name by looking at you?

Make eye contact when speaking to you?

Greet you when you arrive home?

Respond to other’s emotions?

Attempt to involve you in something that he/she is doing

Observe other children playing?

Join in with other children when they are playing?

Take turns in games?

Verbally interact with peers?

Do you have any concerns regarding your child’s social skills?

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

Identify shapes, colors, numbers and letters?

Identify locations, occupations, and functions of objects?

Use pronouns, plurals, and prepositions appropriately?

Identify cause/effect relationships?

Do you have any concerns regarding your child’s academic skills?

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

Walk up and down stairs alternating feet?

Walk around or step over items that are on the floor?

Jump off the ground with both feet?

Kick a playground ball to you?

Throw a playground ball to you?

Catch a ball when thrown?

Show interest in sports?

Any concerns about your child’s gross motor skills?

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

Sleep through the night?

Sleep in his/her own bed without supervision?

Drink from a cup?

Eat a variety of foods (i.e. fruits, veggies, meats, grains)?

Use a spoon and a fork to feed himself or herself?

Remove pull-down garments independently?

Remove socks and shoes independently?

Remove shirts independently?

Put on pull-up garments independently?

Put on socks and shoes independently?

Put on shirts Independently?

Use the toilet Independently?

Any concerns about your child’s self-help skills?

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

Does your child unwrap presents?

Pour water or sand from one object to another?

Turn doorknobs to open doors?

Use one hand consistently?

Use a crayon with hand NOT fisted?

Copy lines and simple shapes?

Write his or her own name?

Use scissors?

Any concerns about your child’s fine motor skills?

Discipline: Please write frequency and method if applicable

Let it go

Send to room

Assign an additional chore

Take away something material

Physical punishment

Reason with child

Ground child

Yell at child

Send to time out

Other

List who is most likely to discipline the child

General Information

List 5 things you would like to see your child do more often

List 5 things you would like to see your child do less often

List any behaviors you are concerned about and how you would like to see them addressed.

Please list the expectation/goals that you have for your child while in a behavioral program

Please list any other information that may be helpful while assessing and/or conducting therapy with your child.

Please list the things that reinforce your child

Food Items

Activities or outings in the community:

Activities at Home:

Toys and Objects:

Other: