This form has been designed to learn more about your child and your family. It will provide useful information for your child’s treatment report and assessment. While it may be time consuming and it may seem repetitive, please do your best to complete it fully and to the best of your ability. If you feel uncomfortable completing any section, please feel free to leave them blank. Required DocumentsBefore beginning the authorization process, we require the following documents in full:A copy of the diagnosis and assessment completed by a Developmental Pediatrician, Psychologist, Neurologist, or Psychiatrist.Acopyof thechild’sproof of insurance.Please send these documents as soon as possible. These documents are required by the insurance company to begin therapy.Client Basic Information Child’s Name* Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Age* Nationality* Gender* Religion / Spirituality* Weight* Height* Dominant Hand* Last 4 Digits of Social Security* Full Address* Who does the child live with?* Diagnosis* Date of Diagnosis* Doctor who Diagnosed* Names of siblings & ages* Do any siblings have autism?*Guardian(s) Basic Information Mother Name* Full Address.* Cell Phone #* Work Phone #* Email Address.* Father Name* Full Address,* Cell Phone #.* Work Phone #.* Email Address,* Occupation* What is the current state of the relationship of the biological parents? MarriedTogetherSeparatedDivorced If divorced or separated, please list step parents or significant others below.Medical History Does your child have a Primary Care Physician?YesNo Name of your child’s pediatrician* May we contact the Physician to collaborate?YesNoNote: If you responded yes to the above question, please sign the release form at the end of the document. Doctor Address* Doctor Phone #* Please list any psychological or medical testing that your child has completed below.TestDateResultsNote: if your child received an ADOS evaluation, please attach a copy of the results. Please check the box any medical diagnosis that apply:*Autism Spectrum DisorderAsperger SyndromeFragile X SyndromeADHDGlobal Developmental DelayADDSpeech DelayCerebral PalsyDown SyndromeNote: if your child received any of these diagnoses, please attach a copy of the results. Has your child experienced any of the following medical problems? Please check the box the ones that have occurred:*Serious accidentHospitalizationSurgeryAsthmaHead injuryHigh feverConvulsions / seizuresAllergiesHearing problemsMeningitisLoss of consciousnessOtherother Please elaborate on any of the above medical problems below: Does the child have his or her immunizations up to date? If he or she does not, please list which immunizations are not up to date. Please attach a copy of the child’s immunization records. Were there any problems or complications during the pregnancy or during delivery? If so, please describe them Is there a history of Autism in the immediate family (parents or siblings)? If so, please elaborate: Is there a history of chronic illness in your family? If so, please describe them: – Did your child have any delays in reaching developmental milestones? Please estimate at which age your child gained the following skills:Skill Acquired (yes or no)Age Skill AcquiredRolled over consistentlySat up unsupportedStood upCrawledWalked unassistedSaid 1st intelligible wordsSaid 2-3 word phrasesUsed sentences regularlyPotty trainedDressed self independently Has your child ever been hospitalized for a physical illness or accident? Please Describe. Has your child ever been hospitalized for a mental illness? Please describe. Has your child had any major illnesses or surgeries? Please describe. Does your child have hearing or vision problems? Please describe. Does your child have a chronic or recurring conditions? Has your child received ABA therapy before? If yes, where, how long and why was he or she discharged from care? Is your child being seen by another behavioral health physician (psychiatrist, social worker, psychologist)? If so, please list his or her name and contact information below. Do we have permission to contact the behavioral health physician?YesNoNote: If yes, please sign the release form at the end of the document. Please list any medication, vitamins or supplements that your child is currently taking:Medication NameDosageLength of timeNote: If your child has been previously evaluated, please provide a copy of the report.Family History Please list the full names of the child’s biological parents:MotherFather Who has guardianship of your child? Please list all the people currently living in the same household as your child:NameAgeRelationship to child Please list any significant people in your child’s life who do not live with him or her:NameAgeRelationship to child Has anyone in your family ever been diagnosed with a mental health disorder or has experienced mental health challenges? If yes, what relation are they to your child and what was there identified mental health diagnosis?Education and Service History Does your child attend school?YesNo Name of school Address Teacher(s), Grade How many days per week? Does your child have and IEP or 504 plan?YesNoNote: If yes, please provide a copy of your child’s most recent IEP or 504 Plan Has your child experienced any of the following problems at school? Please check the box.FightingFew friendsSuspension / expulsionPoor attendancePoor gradesIncomplete workProblem behaviorsExclusion from activities Does your child receive any other services?YesNo Please check the box the services received below:SpeechOccupationalPhysical TherapyAPE Where, when and with whom does the child receive services? Please explain below.Psychological History Has your child had difficulty with the following, Depressed moodFeeling helplessDecreased motivationStressAnxietyShortness of breathRacing heartDizzinessObsessive thoughts and if so, please specify when below: Has your child experienced any of the following, and if so please explain and describe below:Repetitive behaviorsRepetitive vocalizationsObsessive behaviorsSelf injurious behaviors Please answer the questions below using the option on the right that best describes what you may have noticed in your child over the past six months.NeverRarelySometimesOftenAlwaysHow often does she or he have difficulty staying organized?How often does she or he have problems remembering things?How often does she or he fidget or squirm when required to stay seated?How often does she or he have difficulty paying attention during boring or repetitive tasks? How often does she or he misplace items?How often is she or he distracted?How often does she or he interrupt others who are talking?How often does she or he have trouble unwinding after an activity or day?How often does she or he have trouble waiting his/her turn?Open-Ended Functional Assessment Questionnaire Please describe your child’s language abilities below. Please describe your child’s leisure activities (including toys, videos, activities) What are your child’s most common challenging behaviors? (i.e. hitting, biting, screaming) Which behavior is your single most concern? Please describe the range of intensity of your child’s behaviors? Does your child’s behavior occur continuously or in bursts or randomly? Which antecedents are most likely to cause behavior for your child? check the box all that apply.Interrupted activitiesDemandsTransitionsAlone (automatic / sensory)Told NoCan’t communicate a need What expectations and goals do you have for your child while enrolled in this program? What do you consider your child’s strengths? Do you have any worries moving forward with ABA therapy? Is there any other information concerning your child that we may find helpful during assessment or therapy?Skill Assessment Responds to nameYes No Notes Attends to adults voicesYes No Notes Performs 4 different motor actions on commandYes No Notes Selects 4 named items or pictures Yes No Notes Holds items with thumb and index fingerYes No Notes Places items into a container, rings on a peg Yes No Notes Matches 10 identical pictures or objectsYes No Notes Manipulates toys for at least 1 consecutive minute Yes No Notes Indicates that he/she wants to be heldYes No Notes Makes eye contact with children Yes No Notes Engages in parallel play with peersYes No Notes Imitates 2 gross motor movements Yes No Notes Imitates 4 gross motor movements Yes No Notes Imitates others behavior spontaneously Yes No Notes Looks at booksYes No Notes Plays with at least 5 toysYes No Notes Makes eye contact when asking for somethingYes No Notes Plays with cause and effect toys Yes No Notes Imaginative playYes No Notes Play games with rulesYes No Notes Kicks ballYes No Notes Throws ballYes No Notes Sleeps through the nightYes No Notes Drinks from a cupYes No Notes Eats with utensilsYes No Notes Identifies shapesYes No Notes Identifies colorsYes No Notes Identifies lettersYes No Notes Identifies numbersYes No Notes Writes nameYes No Notes Traces letters / numbersYes No Notes Writes letters / numbersYes No Notes Rote counts to 10Yes No Notes Rote counts to 25Yes No Notes Preference Assessment Please list any food / snack items that your child likes: Please list any toys / activities that your child likes: Please list any community outings that your child likes (i.e. bowling, put-put, movies, etc…)I understand that it is important to provide accurate information in order for treatment to be tailored to meet my child’s needs. This information may be used as secondary information for the assessment report. This information is correct as I have described it. Caregiver Signature*Clear Date* Name*FirstLast reCAPTCHASubmitReset
