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Intake Case History & Family Needs Profile
Please make sure to fill out the form below with the correct and required information.
1. INTRODUCTION
How did you hear about us?
*
Social Media
Advertising
Search Engine (Google Search etc.)
Referred By:
Others, please specify:
2. PERSONAL INFORMATION
2.1 Child Information
Child's Full Name
*
الاول
الاخير
Address
*
Gender
*
Male
Female
Date of Birth
*
يوم شرطة مائلة شهر شرطة مائلة سنة
Languages Spoken at Home
*
Child's Strongest Language:
*
2.2 Parent/ Guardian Information
Mother's Full Name
*
الاول
الاخير
Address
Date of Birth
يوم شرطة مائلة شهر شرطة مائلة سنة
Mobile Number
*
Work Phone Number:
Occupation
Employer
Email Address
*
Father's Full Name
*
الاول
الاخير
Address
Date of Birth
يوم شرطة مائلة شهر شرطة مائلة سنة
Mobile Number
*
Work Phone Number:
Occupation
Employer
Email Address
*
Please upload your child's CPR and both parents.
اترك الملفات هنا او
اختار الملفات
أنواع الملفات المقبولة: jpg, png, pdf, الحد الأقصى لحجم الملف: 5 MB, الحد الأقصى للملفات: 10.
File must be jpg, png or pdf with max file size of 5MB.
2.3 Siblings / Household Members (Other than parent/guardian)
Please add the name of each if applicable, otherwise you can skip this section.
Name 1
الاول
الاخير
Date of Birth
يوم شرطة مائلة شهر شرطة مائلة سنة
Relationship
Name 2
الاول
الاخير
Date of Birth
يوم شرطة مائلة شهر شرطة مائلة سنة
Relationship
Name 3
الاول
الاخير
Date of Birth
يوم شرطة مائلة شهر شرطة مائلة سنة
Relationship
Name 4
الاول
الاخير
Date of Birth
يوم شرطة مائلة شهر شرطة مائلة سنة
Relationship
2.4 Emergency Contact Information
Name 1
*
الاول
الاخير
Relationship to Child
*
Contact Number
*
Name 2
الاول
الاخير
Relationship to Child
Contact Number
2.5 Education
Current School
Current Grade
Do you or your child's teacher have any concerns regarding:
Listening Skills
Learning
Behavior
Please Explain
2.6 Services Requested
Location
Select Location
Clinic Based
School Based
Please indicate which type of service you are seeking:
ABA
Speech Therapy
Occupational Therapy
Social Skills
Academic Support Groups
School Readiness Program
Available Times
Sunday
Monday
Tuesday
Wednesday
Thursday
How many hours per day could you commit to sessions?
Please indicate which time of the day your child would be available to attend sessions:
Morning
Afternoon
What are your goals and expectations for the services requested?
*
2.7 Other Services Currently Provided (Speech/PT/OT, etc.)
Other Services Currently Provided (Speech/PT/OT, etc.)
Name of Provider
Services Provided
Times Per Week
3. MEDICAL HISTORY
3.1 Diagnosis (if any)
Do you have any assessments within the last year?
Yes
No
If Yes, please upload or email it to
[email protected]
.
Please upload your files here:
اترك الملفات هنا او
اختار الملفات
أنواع الملفات المقبولة: jpg, png, pdf, الحد الأقصى لحجم الملف: 5 MB.
Primary Diagnosis
Diagnosed By
Diagnosis Date
3.2 Medical History
Medical Conditions (if any)
Allergies and/or Special Diet Information
3.3 Current Medications
Current Medications
Medication
Dosage
Frequency
4. BEHAVIORAL AND LANGUAGE ASSESSMENT
4.1 Expressive and Receptive Verbal Skills
Does your child ever use any words? If yes please describe the amount of words and give examples of what he/she says:
*
If no, does your child babble? If yes, please list the sounds you have heard:
*
Can your child ask for things he/she wants with words? Cookie, juice, ball, push me? If yes please list the items your child requests with words:
*
If no, how does your child let you know what he/she wants? Please tick on the options that apply:
Gestures
Pictures
Pointing
Crying
Pulling an Adult
Grabbing
Sign Language
Other
Can your child label things in a book or on flashcards? If so, please estimate the number of things your child can label and give up to 5 examples:
Can your child imitate words you say? For example,if you say,“say ball” will he/she say “ball”? Will he/she imitate phrases? And if you say, “I love you” will he/she repeat “I love you”? If yes, please describe:
*
Can your child fill in the blanks to songs? For example, if you say,“Twinkle Twinkle little...” Will your child say “star?” Please list a few songs that your child can fill in words or phrases to:
Will your child answer WH questions (with no picture)? For example if you say, “What flies in the sky?” Will your child answer “bird” or “plane”? and will he/she name at least three animals or colors if you ask him/her to?:
Will your child answer WH questions (with no picture)? For example if you say, “What flies in the sky?” Will your child answer “bird” or “plane”? and will he/she name at least three animals or colors if you ask him/her to?:
4.2 Visual Skills
Will your child match identical objects to objects, pictures to pictures, and pictures to objects if you tell him/her to “match”?
Yes
No
Will your child complete age-appropriate puzzles?
Yes
No
4.3 Receptive Language Skills Motor Imitation
Is your child able to imitate simple motor movements such as clapping, waving?
Yes
No
Will your child touch his/her body parts for example if you say “Touch your nose”?
Yes
No
Will your child copy your actions with toys if you tell him/her “do this”? For example, if you take a car and roll it back and forth and you tell your child “Do this”. Will your child copy?
Yes
No
If you tell your child to get his/her shoes or pick up his/her cup, does he/she follow your direction without gestures?
Yes
No
4.4 Play Skills
Does your child...
Look at books?
*
Yes
No
Comments
Play with cause/effect toys (i.e.: Jack in the Box)?
*
Yes
No
Comments
Complete task completion toys (i.e.: puzzles, beads)?
*
Yes
No
Comments
Play with toys by using them like real items (i.e. uses a play spoon to pretend to eat)?
*
Yes
No
Comments
Play simple games like ring around the rosy?
*
Yes
No
Comments
Construct items using blocks, legos, or other items?
*
Yes
No
Comments
Play games with rules (i.e. Memory games)?
*
Yes
No
Comments
Engage in dress up or role play (i.e. pretending to be a barber)?
*
Yes
No
Comments
Play appropriately on his or her own for up to 5 minutes?
*
Yes
No
Comments
What are your principal concerns? regarding your child’s play skills?
*
Yes
No
Comments
4.5 Social Skills
Does your child....
Respond to his or her name by looking at you when you call it?
Yes
No
Comments
Make eye contact when speaking to you?
Yes
No
Comments
Greet you when you arrive home?
Yes
No
Comments
Respond to others’ emotions?
Yes
No
Comments
Attempt to involve you in something that he/she is doing to share interest (not b/c he or she needs your help)?
Yes
No
Comments
Observe other children playing?
Yes
No
Comments
Join in with other children when they are playing?
Yes
No
Comments
Take turns in games?
Yes
No
Comments
Verbally interact with peers?
Yes
No
Comments
Accept ‘No’
Yes
No
Comments
Wait for his/her turn
Yes
No
Comments
Are there any safety concerns we should be aware of?
Yes
No
Comments
What are your principal concerns regarding your child’s social skills?
4.6 Self-Help Skills
Does your child....
Sleep through the night?
Yes
No
Comments
Sleep in his/her own bed without supervision?
Yes
No
Comments
Sit at a table?
Yes
No
Comments
Drink from a cup?
Yes
No
Comments
Eat a variety of foods (i.e. fruits, veggies, meats, grains)?
Yes
No
Comments
Use a spoon and a fork to feed himself or herself? (Self-feed)
Yes
No
Comments
Remove pull-down garments independently?
Yes
No
Comments
Remove socks and shoes independently?
Yes
No
Comments
Remove shirts independently?
Yes
No
Comments
Put on pull-up garments independently?
Yes
No
Comments
Put on socks and shoes Independently?
Yes
No
Comments
Put on shirts Independently?
Yes
No
Comments
Use the toilet independently?
Yes
No
Comments
What are your principal concerns regarding your child’s self-help skills?
4.7 Fine Motor Skills
Does your child...
Unwrap presents?
Yes
No
Comments
Pour water or sand from one object to another?
Yes
No
Comments
Turn doorknobs to open doors?
Yes
No
Comments
Use one hand consistently?
Yes
No
Comments
Use a crayon with hand NOT fisted?
Yes
No
Comments
Copy lines and simple shapes?
Yes
No
Comments
Write his or her own name?
Yes
No
Comments
Use scissors?
Yes
No
Comments
What are your principal concerns regarding your child’s fine motor skills?
4.8 Gross Motor Skills
Does your child....
Walk up and down stairs with alternating feet?
Yes
No
Comments
Walk around or step over items that are on the floor?
Yes
No
Comments
Jump off the ground with both feet?
Yes
No
Comments
Kick a playground ball to you?
Yes
No
Comments
Throw a playground ball to you?
Yes
No
Comments
Catch a ball when thrown?
Yes
No
Comments
Show interest in sports?
Yes
No
Comments
What are your principal concerns regarding your child’s gross motor skills?
4.9 Academic Skills
Does your child....
Identify shapes, colors, numbers and letters?
Yes
No
Comments
Identify locations, occupations, and functions of objects (i.e.; the refrigerator keeps things cold)? يم ر ز
Yes
No
Comments
Use pronouns, plurals and prepositions appropriately?
Yes
No
Comments
Identify cause/effect relationships?
Yes
No
Comments
What are your principal concerns regarding your child’s academic skills?
4.10 Challenging Behaviors
Please list any challenging behaviors that your child may exhibit and complete the table accordingly.
Tantrums
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Failing to Follow Instructions
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Aggression
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Running Away / Eloping
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Self-Injurious Behaviors
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Eating Inedible Objects (Pica)
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Other
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Wants something but doesn't ask for it appropriately
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
4.11 Self-Stimulatory Behaviors
Please list any self-stimulatory/repetitive behaviors that your child may exhibit and complete the table accordingly.
Vocal (repeating vocalizations, words or phrases)
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Preoccupations with items, topics, etc.
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Repetitive motor mannerisms (hand flapping, spinning items, lining up objects, etc.)
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
Routine behaviors (insisting on the same cup, same route in the car)
Please describe the behavior.
What typically happens immediately before, or triggers the behavior?
Told “No” or preferred activity is Terminated
Not receiving attention from caregivers
Asked to do something difficult or unpreferred
Other
How many times per day or week does this behavior occur? If the behavior lasts for more than 10 seconds, list the average duration of the behavior as well.
Daily
Weekly
Monthly
Never
Other
Other, Please indicate:
What typically happens after the behavior, or, what do you do when this behavior occurs?
Offer objects/food to stop behavior
Ask what is wrong
Comfort and try to soothe your child
Ignore and wait to see if they calm down
Restrain
Tell them there will be punishment
Follow through with what was asked
5. REINFORCEMENT ASSESSMENT
Prior to beginning the pairing process, it is important to identify ALL of the child’s motivators or reinforcers. Many children have very specific reinforcers and may engage with them in certain ways. Please provide as much detail as possible. Please indicate your child’s preferences below. Please provide specifics if possible (e.g., what kind, brand, type, etc.). Cross off (X) if child hates.
5.1 What are your child’s preferences (likes and dislikes)?
Puzzles:
*
Musical Instruments:
*
Action Figures:
*
Games:
*
Play Dough:
*
Notes:
*
Other:
5.2 What are your child’s sensory preferences?
Auditory (Sounds):
*
Visual (light, colors):
*
Tactile (contact, textures):
*
Kinesthetic (movement):
*
Olfactory (smells):
*
Gustatory (tastes):
*
5.3 What are your child’s entertainment preferences?
Movies:
*
TV Shows:
*
Animation/Cartoons:
*
Music:
*
Video Games:
*
Board Games/Other:
5.4 What are your child’s preferences for computer activities?
Games / Apps:
*
Internet Sites:
*
5.5 What are your child’s favourite snacks/foods?
Candy:
*
Cookies:
*
Chips:
*
Ice Cream:
*
Fruit:
*
Crackers:
*
Pretzels:
*
Other:
5.6 What are your child’s favourite beverages?
Soda:
Juice:
*
Water:
*
Milk:
*
Other:
Comments
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