* Required Information

PATIENT INFORMATION

INSURANCE INFORMATION

Primary Insurance:
Secondary Insurance:

PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD


CLIENT INTAKE FORM BEHAVIORAL INTERVENTION SERVICES Background Information History

Siblings:

PREVIOUS AND CURRENT INTERVENTIONS (Speech Therapy, Occupational Therapy, Behavioral Therapy, other services)




Please list all current medications (including homeopathic, herbal or vitamin-based remedies)

MEDICATION
DOSAGE/FREQUENCY
PRESCRIBED FOR

DEVELOPMENTAL HISTORY

SELF-HELP SKILLS Please describe your child’s current level of functioning in the following areas:

PROBLEM BEHAVIORS Please describe any problematic behavior(s). Examples are: non-compliance, aggression, head banging, tantrum, etc.

Behavior #1
Behavior #2
Behavior #3
Behavior #4

SOCIAL BEHAVIOR

LANGUAGE

EDUCATIONAL BACKGROUND

SPIRITUAL Respecting your individual family beliefs is important to the staff at Journey’s. The following questions are voluntary and are not required to be considered for services.

GOALS AND OBJECTIVES
Please list several goals that you would like your child to achieve by participating in ABA services (e.g., eating a wider variety of foods, using words to make needs known, speaking in sentences, playing appropriately with toys, developing and/or maintaining friendships, etc.)

FAMILY HISTORY Please list family history of developmental disabilities, mental health illness, or learning disabilities