Client Questionnaire

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Date Completed

Client Name

Client Age:

Name of Person Giving Information

Relation to Client

Contact Email

Contact Phone Number

Type of Insurance Coverage

Private

Medicaid

Private and Medicaid

Private Pay

Name of Primary Insurance Company

Name of Secondary Insurance Company

If none mark N/A

Household/Family Information

Parents Relationship Status:

Single

Married

Divorced or Separated

Other

Primary Language(s) Spoken at Home

Other Languages Spoken at home

Interpreter requested?

Yes

What town does the client live in?

Other Information About Your Family

Cultural considerations, family dynamics, or anything else you want us to know about working with you. Mark N/A if none.

Type of Service Requested and Availability (This is not a guarantee of service and/or time. Sessions are based on staff availability, clinical necessity, and schedule openings.)

What type of service are you interested in? (ABA Coaching is required for all parents.) Please click all that apply

1:1 Sessions

1 CBT and 1 Client

Social Skills Group

1 CBT and up to 5 Clients

Group ABA Coaching Only

1 BCBA and multiple parents

1:1 ABA Coaching Only

1 BCBA and 1 parent

Service Location Requested (Please note that location is partially determined by staff availbility and clinical necessity.) Please click all that apply

Clinic

School

Telehealth

Client Times Available Please click all that apply

Morning

Afternoon

Evening

Client Days Available Please click all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Who will primarily be attending parent training?

ABA Coaching is required for parents, and is typically 1 time per week.

Parent Times Available (If different from client) Please click all that apply

Morning

Afternoon

Evening

Parent Days Available (If different from client) Please click all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Supports in Place for Parent(s)

I/We attend counseling sessions.

I/We attend other forms of therapy.

I/We participate in religious activities.

I/We attend support groups.

I/We have extended family that we rely on.

None of the Above

Please list any other supports in place for parents:

Additional Information

If you had to pick one, what would be your primary focus for your child right now

Skill Acquisition Behavior Management

Major Goals for the Client

What other types of therapy is your child currently participating in? (Please include how often.)

Where are they going for therapy? (List name of organization/provider for each)

What other types of therapy have you tried in the past? (Please include provider, and reason for stopping.)

Are there any medical issues with your child and/or family?

Is there a history of mental illness, drug abuse, and/or alcohol use in your child's family?

What prescription medications are your child currently taking? (Please include dose and frequency. Mark N/A if none)

Is your child allergic to anything? (Please include medication, food, animal, and/or plant) (Mark N/A if no)

Is there anything else that you would like to let us know about you, your family, or your child?

Mark N/A if none

I was assisted in preparing this form by: (Include full name and role)

Mark N/A if no one helped

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Client Questionnaire

The Behavior Business LLC

Household/Family Information

Type of Service Requested and Availability (This is not a guarantee of service and/or time. Sessions are based on staff availability, clinical necessity, and schedule openings.)

Additional Information

The Behavior Business LLC

The Behavior Business LLC