Behavior Intake Form

Child’s Information:

Last Name

First Name

Middle Name

Gender

Date of Birth

Age

Current Address

Primary Family Email

Mother’s Information:

Full Name

Cell Number

Occupation

Place of Employment

Work Number

Father’s Information:

Full Name

Cell Number

Occupation

Place of Employment

Work Number

Who does the child live with?

Are parents

married divorced

If divorced, who has custody?

If applicable, please list stepparents

If divorced, list for how long?

Provide the names and ages of all siblings living in the household

Provide the names and ages of any other family members living in the household

Child’s Primary Pediatrician Information:

Doctor’s Name

Doctor’s Phone

Fax#

Address

City

State

Zip Code

Child’s Medical Diagnosis and Date

Pregnancy: If applicable, please select 'Yes' and provide details

Any complications or health problems

Yes No

Any emotional Trauma or Stress

Yes No

Was bed rest recommended

Yes No

Any medications during pregnancy

Yes No

Was birth mother physically active

Yes No

Any exposure to alcohol

Yes No

Any exposure to drugs

Yes No

If yes to any of the above, provide details

Labor/Delivery: if applicable, select 'Yes' and describe

Full Term

Yes No

Early Delivery Vaginal Delivery

Yes No

Induced Labor

Yes No

Forceps/Vacuum

Yes No

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, select 'Yes' and describe who in the family had the condition

Autism Spectrum

Yes No

Learning Problem

Yes No

Disabilities

Yes No

ADD/ADHD

Yes No

Depression

Yes No

Bipolar Disorder

Yes No

Anxiety Disorders (OCD, Phobias)

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 what age and comments

Rolled over consistently

Crawled (was crawling phrase brief?)

Walked unassisted

Fed self

Dry through the night for more than 6 months

The first word spoken that was understood by a stranger

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, select 'Yes' and provide comments

Does your child have problems relating to or playing with others?

Yes No

Comment

Fights frequently with playmates?

Yes No

Comment

Prefers playing with younger children?

Yes No

Comment

Has difficulty making friends?

Yes No

Comment

Prefer to play alone?

Yes No

Comment

Is your child the aggressor in group games?

Yes No

Comment

Is your child a follower in group games?

Yes No

Comment

Is your child a leader in group games?

Yes No

Comment

Other

Education

Does your child attend school?

Yes No

Please list the name of the school

Does your child have a primary teacher?

Yes No

Please list the name

Does your teacher have concerns about your child?

Yes No

Please list concerns

Does your child have a favorite class/subject?

Yes No

If yes, please list the subject (s)

Does your child have a least favorite class/subject?

Yes No

If yes, please list the subject (s)

Has your child ever repeated a grade?

Yes No

If so, what grade?

Other

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

Has your child been diagnosed with Autism?

Yes No

Explain

Pervasive Developmental Disorder?

Yes No

Explain

Nonverbal Learning Disorder?

Yes No

Explain

Sensory Integration Disorder?

Yes No

Explain

Has your child had any significant falls or injuries?

Yes No

Explain

Has your child ever been hospitalized?

Yes No

Reason

Does your child have any allergies?

Yes No

Please list the allergies

Does your child have any compulsive behaviors?

Yes No

Explain

Has your child had a head injury?

Yes No

Occurrence, location on skull?

Any hearing problems?

Yes No

Date of the last test

Any vision problems?

Yes No

Date of the last test

Other

Developmental Team: Check the specialist and for each specialist, list the name, dates seen, and findings:

Allergist

Name

Dates seen

Findings

Audiologist

Name

Dates seen

Findings

Speech Pathologist

Name

Dates seen

Findings

Gastroenterologist

Name

Dates seen

Findings

Neurologist

Name

Dates seen

Findings

Nutritionist/Dietitian

Name

Dates seen

Findings

Occupational Therapist

Name

Dates seen

Findings

Ophthalmologist

Name

Dates seen

Findings

Physical Therapist

Name

Dates seen

Findings

Psychiatrist

Name

Dates seen

Findings

Psychologist

Name

Dates seen

Findings

Cardiologist

Name

Dates seen

Findings

Other

Specialist

Name

Dates seen

Findings

List all current medications, dosages, frequency taken, and reason

List all allergies to medicine, if the reaction is mild or severe, and the type of reaction

Issues/Problems: Select Yes if applicable, and write in the age and grade and explain

Problems with eating?

Yes No

Age, grade and explain

Socially isolated from peers?

Yes No

Age, grade and explain

Problems making/keeping friends?

Yes No

Age, grade and explain

Problems getting to sleep?

Yes No

Age, grade and explain

Problems controlling temper?

Yes No

Age, grade and explain

Problems sleeping through the night?

Yes No

Age, grade and explain

Problems waking up?

Yes No

Age, grade and explain

Fatigue/tiredness during the day?

Yes No

Age, grade and explain

Soiling?

Yes No

Age, grade and explain

Nightmares?

Yes No

Age, grade and explain

Bedwetting?

Yes No

Age, grade and explain

History of abuse?

Yes No

Age, grade and explain

Alcohol/drug use/abuse?

Yes No

Age, grade and explain

School concentration?

Yes No

Age, grade and explain

Grades dropping?

Yes No

Age, grade and explain

Sadness or Depression?

Yes No

Age, grade and explain

Medical Conditions
Check all that apply. Please list the age and explain.

Sinus Conditions

List age and explain

Constipation

List age and explain

Ear Infections

List age and explain

Chronic Cough

List age and explain

Asthma

List age and explain

Frequent Colds

List age and explain

Strep Throat

List age and explain

High Fever

List age and explain

Anemia

List age and explain

Meningitis

List age and explain

Fitful Sleep

List age and explain

Bedwetting

List age and explain

Antibiotic Use

List age and explain

Nail Biting

List age and explain

Mumps

List age and explain

Diarrhea

List age and explain

Skin Problems

List age and explain

Seizures

List age and explain

Allergies

List age and explain

Diptheria

List age and explain

Encephalitis

List age and explain

Chicken Pox

List age and explain

Measles

List age and explain

German Measles

List age and explain

Tuberculosis

List age and explain

Whooping Cough

List age and explain

Limited Food Intake

List age and explain

Scarlet Fever

List age and explain

Rheumatic Fever

List age and explain

Difficulty Falling Asleep

List age and explain

Extended Thumb Sucking

List age and explain

Chronic Stomach Aches

List age and explain

Special Education: Check all that apply, and for the checked items, note the age and explanation.

Enrolled in a special ED class

Age and explain/comment

Occupational Evaluation

Age and explain/comment

Adaptive Technology Evaluation

Age and explain/comment

Consultation

Age and explain/comment

504 plan

Age and explain/comment

Collaborative Education

Age and explain/comment

Psychological Evaluation

Age and explain/comment

Pull-Out

Age and explain/comment

Special Program

Age and explain/comment

Speech Evaluation

Age and explain/comment

Resource Classroom

Age and explain/comment

Behavior Intervention Plan

Age and explain/comment

Team Taught Classes

Age and explain/comment

Self-Contained Classroom

Age and explain/comment

Physical Therapy Evaluation

Age and explain/comment

Psychoeducational Center

Age and explain/comment

I.E.P.

Age and explain/comment

Other

Specify, age and explain/comment

Extracurricular Activities: Check all that apply and note the age and comment.

Football

Age and comment

Baseball

Age and comment

Karate

Age and comment

Piano

Age and comment

Dance

Age and comment

Music

Age and comment

Cheerleading

Age and comment

Basketball

Age and comment

Scouts

Age and comment

Soccer

Age and comment

Gymnastics

Age and comment

Swimming

Age and comment

Other

Age and comment

Language Skills Assessment: If applicable, select 'Yes' and explain.

Does your child look at books?

Yes No

Explain

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

Yes No

Explain

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

Yes No

Explain

Play with toys like they are real items?

Yes No

Explain

Play games like Ring Around the Rosy?

Yes No

Explain

Construct items using blocks and Legos?

Yes No

Explain

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

Yes No

Explain

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

Yes No

Explain

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

Yes No

Explain

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

Yes No

Explain

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

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

Yes No

Explain

Make eye contact when speaking to you?

Yes No

Explain

Greet you when you arrive home?

Yes No

Explain

Respond to other’s emotions?

Yes No

Explain

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

Yes No

Explain

Observe other children playing?

Yes No

Explain

Join in with other children when they are playing?

Yes No

Explain

Take turns in games?

Yes No

Explain

Verbally interact with peers?

Yes No

Explain

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

Yes No

Explain

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

Identify shapes, colors, numbers, and letters?

Yes No

Comment

Identify locations, occupations, and functions of objects?

Yes No

Comment

Use pronouns, plurals, and prepositions appropriately?

Yes No

Comment

Identify cause/effect relationships?

Yes No

Comment

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

Yes No

Comment

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

Walk up and down stairs alternating feet?

Yes No

Comment

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

Yes No

Comment

Jump off the ground with both feet?

Yes No

Comment

Kick a playground ball to you?

Yes No

Comment

Throw a playground ball to you? Catch a ball when thrown?

Yes No

Comment

Shows interest in sports?

Yes No

Comment

Any concerns about your child’s gross motor skills?

Yes No

Comment

Self-Help Skills: if applicable, select 'Yes' and provide comments.

Sleep through the night?

Yes No

Comment

Sleep in his/her bed without supervision?

Yes No

Comment

Drink from a cup?

Yes No

Comment

Eat various foods (i.e. fruits, veggies, meats, grains)?

Yes No

Comment

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

Yes No

Comment

Remove pull-down garments independently?

Yes No

Comment

Remove socks and shoes independently?

Yes No

Comment

Remove shirts independently?

Yes No

Comment

Put on pull-up garments independently?

Yes No

Comment

Put on socks and shoes independently?

Yes No

Comment

Put on shirts Independently?

Yes No

Comment

Use the toilet Independently?

Yes No

Comment

List any concerns about your child’s self-help skills

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

Does your child unwrap presents?

Yes No

Comment

Pour water or sand from one object to another?

Yes No

Comment

Turn doorknobs to open doors?

Yes No

Comment

Use one hand consistently?

Yes No

Comment

Use a crayon with hand NOT fisted?

Yes No

Comment

Copy lines and simple shapes?

Yes No

Comment

Write his or her name?

Yes No

Comment

Use scissors?

Yes No

Comment

List any concerns about your child’s fine motor skills

Discipline: Please check if applicable and write frequency and method

Let it go

Frequency and method

Send to room

Frequency and method

Assign an additional chore

Frequency and method

Take away something material

Frequency and method

Physical punishment

Frequency and method

Reason with child

Frequency and method

Ground child

Frequency and method

Yell at child

Frequency and method

Send to time-out

Frequency and method

Other

Frequency and method

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 them addressed

Please list the expectations/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