Intake Case History & Family Needs Profile

Please make sure to fill out the form below with the correct and required information.

  • 1. INTRODUCTION

  • 2. PERSONAL INFORMATION

  • 2.1 Child Information

  • DD slash MM slash YYYY

  • 2.2 Parent/ Guardian Information

  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • Drop files here or
    Accepted file types: jpg, png, pdf, Max. file size: 5 MB, Max. files: 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.
    • DD slash MM slash YYYY
    • DD slash MM slash YYYY
    • DD slash MM slash YYYY
    • DD slash MM slash YYYY

    • 2.4 Emergency Contact Information

    • 2.5 Education

    • 2.6 Services Requested

    • Available Times

    • 2.7 Other Services Currently Provided (Speech/PT/OT, etc.)

    • Name of ProviderServices ProvidedTimes Per Week 

    • 3. MEDICAL HISTORY

    • 3.1 Diagnosis (if any)

      If Yes, please upload or email it to [email protected].
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      Accepted file types: jpg, png, pdf, Max. file size: 5 MB.
      • Primary DiagnosisDiagnosed ByDiagnosis Date 

      • 3.2 Medical History

      • 3.3 Current Medications

      • MedicationDosageFrequency 

      • 4. BEHAVIORAL AND LANGUAGE ASSESSMENT

      • 4.1 Expressive and Receptive Verbal Skills

      • 4.2 Visual Skills

      • 4.3 Receptive Language Skills Motor Imitation

      • 4.4 Play Skills

        Does your child...

      • 4.5 Social Skills

        Does your child....

      • 4.6 Self-Help Skills

        Does your child....

      • 4.7 Fine Motor Skills

        Does your child...

      • 4.8 Gross Motor Skills

        Does your child....

      • 4.9 Academic Skills

        Does your child....

      • 4.10 Challenging Behaviors

        Please list any challenging behaviors that your child may exhibit and complete the table accordingly.

      • Tantrums

      • Failing to Follow Instructions

      • Aggression

      • Running Away / Eloping

      • Self-Injurious Behaviors

      • Eating Inedible Objects (Pica)

      • Other

      • 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)

      • Preoccupations with items, topics, etc.

      • Repetitive motor mannerisms (hand flapping, spinning items, lining up objects, etc.)

      • Routine behaviors (insisting on the same cup, same route in the car)

      • 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)?

      • 5.2 What are your child’s sensory preferences?

      • 5.3 What are your child’s entertainment preferences?

      • 5.4 What are your child’s preferences for computer activities?

      • 5.5 What are your child’s favourite snacks/foods?

      • 5.6 What are your child’s favourite beverages?

      • This field is for validation purposes and should be left unchanged.