Client Intake Form - A.G.E.S Learning Solutions

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Client Intake Form

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Please complete A.G.E.S.’s Secure Form.

Client's Gender
Parent Details
Gender
Gender
Gender
Gender
Guardian Details
Other Details
Emergency Relationship to Family
Developmental History
Medical History
Can we contact the PCP?
Does the client have seizures?
Has the client had seizures in the past?
Is client currently taking seizure medication?
Does client have or ever had an infectious disease?
General Behavior
Non‑Compliance
Tantrums
Aggression
Aggression Towards
Running Away
Other Behaviors to Mention
Self Stimulatory Behaviors
Social Behaviors
Does client give eye contact?
Does the client respond to his/her name?
Does the client come to you for comfort?
Does the client greet you in anyway when he/she sees you?
Does the client show interest in other people?
Does the client attempt to involve you in something he/she is doing?
Does the client get involved with something you are doing?
Does the client respond better to any particular person?
General Language
Did the client have speech that he/she lost?
Was the client ill at the time of speech loss?
Does the client cry to let you know if they want something?
Does the client cry to let you know if they want something?
Does the client take you or point to what he/she wants?
Does the client say what they want?
Receptive Language
Does the client follow verbal instructions without visual cues?
Expressive Language
Can the client hold a conversation about a favorite topic?
Educational Background
Does the client attend school or other program?
Does the client have an aide/shadow while attending school/program?
Is the aide/shadow with the client fulltime or parttime?
Is the reacurrent IEP/IPP/IFSP/IPP/Individual Plan?
Are you satisfied with the client's program?
Reason for Seeking Services
Does the client have a diagnosis?
Was this diagnosis firm or questionable?
Client's Current and Past Services
Is the client seeing anyother behavioral health clinicians?
Would you like us to contact the behavioral health clinician?
Goals and Objectives
Referral Source
How did you hear about us?
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