Client Intake Form

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

Client's Full Name
Client's Nickname
Client's DOB
date_range
Client's Age
Client's Gender
Client's Address
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Client's City
Client's Zip Code
Client's Phone Number
Parent Details
Parent's Full Name
Parent's Cell Phone
Parent's Home Phone
Parent's Work Phone
Sibling 1 Name
Age
Gender
Sibling 2 Name
Age
Gender
Sibling 3 Name
Age
Gender
Sibling 4 Name
Age
Gender
Guardian Details
Parent/Guardian Full Name
Parent/Guardian Cell Phone
Parent/Guardian Home Phone
Parent/Guardian Work Phone
Other Details
Family Religious Preference
Family Primary Language
Family Secondary Language
Emergency Contact Name
Emergency Relationship to Family
Developmental History
List any childhood illnesses (Please list the child’s age, the illness and the treatment prescribed)
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How does the client sleep now?
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How does the client eat now?
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Describe the client's typical diet. Allergies? Gluten?
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Toileting
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Feeding
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Showering / Bathing
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Medical History
Diagnosis
When was client diagnosed?
List names, addresses and phonenumbers of medical professionals involed with client (Pediatrician, counselor, etc)
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Can we contact the PCP?
Hospitalizations / Operations / Other Medical Conditions
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Does the client have seizures?
Has the client had seizures in the past?
Frequency of Seizures
Seizure Length
Seizure Type
Is client currently taking seizure medication?
What seizure medication is s/he taking?
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Please list all major medical conditions that run in your family
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Please list any complications during your pregnancies or births
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Does client have or ever had an infectious disease?
Please list the infectious disease(s) client has had
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What precautions are currently taken to prevent the spread of the disease(s)?
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General Behavior
Non‑Compliance
Describe the context in which the non‑compliance usually occurs
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Consequences used for Non‑Compliance
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Tantrums
Describe the context in which the tantrums occurs
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Describe nature of tantrum (i.e., throws self on floor, etc)
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Duration of typical tantrum
Frequency of tantrums
Consequences Used for Tantrums
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Aggression
Aggression Towards
Describe the context in which the Aggression occurs
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Describe nature of Aggressive behaviors
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Frequency of Aggressive behaviors
Consequences used for Aggression
Running Away
Describe the context in which Running Away occurs
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Frequency of Running Away
Consquences Used for Running Away
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Other Behaviors to Mention
Other Behaviors
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Other Behavior Frequency
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Consequences Used for Other Behavior
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Self Stimulatory Behaviors
Repetitive Mannerisms (hand flapping, flicking, gazing, lining up objects, hoarding, toe walking, running back and forth, etc)
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Unusual attachments to objects
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Repeats previously heard words out of context (echolalia)
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Verbalizing in a repetitive manner (eeesounds, babbling, screaming, etc)
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Difficulty with transitions or changes in routine
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Unusual interest in the sight, feel, sound or smell of things
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Unusual preoccupations/obsessions (anything he/she likes to do repeatedly)
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Social Behaviors
Does clients how affection? How?
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How does client play or interact with peers?
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How does client play with toys or leisure objects?
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Please list client’s favorite items, toys, activities, music, food, games, etc
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Does client give eye contact?
Whom does the client have good eye contact towards?
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Under what circumstances is the eye contact given?
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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?
How does the client greet you?
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Does the client show interest in other people?
Whom and how does the client shows interest in other people?
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Does the client attempt to involve you in something he/she is doing?
Please describe some examples of how the client involves you
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Does the client get involved with something you are doing?
Please describe some examples of how the client gets involved with what you are doing
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Does the client respond better to any particular person?
Who does the client respond better to?
Why do you think the client responds to that person better?
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General Language
Did the client have speech that he/she lost?
What age did the client start to lose speech?
Was the client ill at the time of speech loss?
What is the client's usual way of communicating?
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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?
How much do you think the client understands?
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Expressive Language
Does the client have anywords? Give examples
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Are the words the client has used in context or out of context?
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Does the client babble or combine sounds that the combined sounds resemble some speech?
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Are there anywords that the client imitates? Please list the words
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What is the average length of the client's utterances
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Are there problems with the client's articulation or into nation of speech?
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Can the client hold a conversation about a favorite topic?
Describe how the client holds a conversation about their favorite topic
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List any additional comments you would like to make regarding the client's speech and language
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Educational Background
Does the client attend school or other program?
What school/program does the client attend?
What type of program does the client attend?
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How long has the client been attending school/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?
Please provide the IEP/IPP/IFSP/IPP/Individual Plan
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Are you satisfied with the client's program?
How are you satisfied with the program?
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How are you NOT satisfied with the program?
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Reason for Seeking Services
Does the client have a diagnosis?
What is the current diagnosis?
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Date Diagnosed
date_range
Age at Diagnosis
Who made the diagnosis?
Was this diagnosis firm or questionable?
What are your goals and expectations from us?
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Client's Current and Past Services
Type of Service 1
Service Provider 1
Duration of Service 1
Client's Response to Service 1
Type of Service 2
Service Provider 2
Duration of Service 2
Client's Response to Service 2
Type of Service 3
Service Provider 3
Duration of Service 3
Client's Response to Service 3
Type of Service 4
Service Provider 4
Duration of Service 4
Client's Response to Service 4
Is the client seeing anyother behavioral health clinicians?
What behavioral health clinicians is the client seeing?
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Would you like us to contact the behavioral health clinician?
Please provide the behavioral health clinician contact information
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Goals and Objectives
Please list some goals that you would like the client to achieve
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Is there other additional information you would like us to know about the client/your family?
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Do you currently have any relevant legal issues?(example:taking action against your school system, custody, etc)
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Referral Source
How did you hear about us?
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