Central California Autism Center
Client Intake Form
A. Background Information and History
Child’s Name:
Last
First
Date of Birth:
Boy:
Middle Initial
Current Age:
Girl:
Father’s Name:
Mother’s Name:
Mother’s Occupation:
Business #:
Father’s Occupation:
Business #:
Address:
Number
Street
Apt.
City
State/Province
Zip Code
Home Telephone Number :(
)
Cell Phone:(
)
Email:
Siblings: How many?
1. (Name)
(sex)
(age)
2. (Name)
(sex)
(age)
3. (Name)
(sex)
(age)
4. (Name)
(sex)
(age)
B. Diagnosis:
(DSM code, if known)
Diagnosed By:
Date of Diagnosis:
Age at Diagnosis:
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Central California Autism Center
C. Current Clinicians:
Pediatrician:
Immunologist:
Allergist:
Neurologist:
Psychologist/Psychiatrist:
Speech Pathologist:
Occupational Therapist:
Other:
D. Diagnostic Testing:
Please review the following and provide information relating to any medical testing your child may have
undergone. List date, who conducted test, and results.
Psychological (including any IQ testing):
Immunological/Allergy:
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E. Previous and Current Treatments:
(Speech, Occupational Therapy, Behavioral Therapy, Other DIS services)
Treatment 1:
Type of Treatment:
Treatment Provider:
Duration of Treatment:
Child’s Age:
Treatment 2:
Type of Treatment:
Treatment Provider:
Duration of Treatment:
Child’s Age:
F. Medical History
Please list all medications previously taken.
Please list current medications (including homeopathic, herbal, or vitamin-based remedies)
1.
Medication
for Treatment of
Start Date
for Treatment of
Start Date
Prescribed By
2.
Medication
Prescribed By
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Central California Autism Center
G. Developmental History
Describe pregnancy and delivery:
Please list any childhood illnesses, list the child’s age, the illness, and the treatment prescribed (ear infections
listed separately)
Number of ear infections:
How these were treated:
Did you ever suspect a hearing difficulty? Yes
No
Is you child hypersensitive to sound? Yes
No
What sounds bother your child?
List the onset of these developmental milestones:
Crawling:
Sitting:
Walking:
Sleeping through the night:
Eating solid foods:
Drinking milk (cow or soy):
Speech:
How does you child sleep now?
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H. Behavior
Please describe any problematic behavior. Antecedents refer to causes or precipitating events, instructions or situations.
Non Compliance: Yes
No
Frequency (daily, weekly, monthly)
Antecedents:
Consequences Used:
Tantrums: Yes
No
Frequency:
Antecedents:
Consequences Used:
Aggression:Yes
No
Frequency:
Antecedents:
Consequences Used:
Running Away:Yes
No
Antecedents:
Consequences Used:
Other Behaviors (please describe)
I. Self Stimulation
Repetitive mannerisms: (hand flapping, flicking, gazing, lining up objects, hoarding objects, toe walking, running
back and forth, etc.)
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I Cont.
Unusual attachment to objects:
Repeating previously heard words our of context– echolalia:
Difficulties with transitions or changes in routine:
Unusual interest in the sight, feel, sound, or smell of things:
Unusual preoccupations/obsessions: (anything he or she likes to do repeatedly):
Verbalizing in a repetitive manner: ( i.e. “eee” sounds, babbling, screaming, etc.):
J. Social Behavior
Does your child show affection? How?
Does your child have good eye contact? How and with whom?
Does your child respond to his or her name? Yes
No
Does your child come to you for comfort? Yes
No
Does your child respond better to any particular person? Yes
No
To whom?
Does your child greet you in any way when he or she sees you? Yes
No
How?
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J Cont.
Does your child show interest in other people? Yes
No
How?
Does your child attempt to involve you in something he or she is doing or get involved in something you or your
family is doing? Yes
No
Please describe:
K. Language
Did your child have speech that he or she lost? Yes
No
If yes, at what age did he or she start to lose speech?
Was he or she ill at the time of the loss? Yes
No
What is your child’s usual way of communicating?
Does your child cry to let you know he or she wants something? Yes
No
Does your child take you to or point to what he or she wants? Yes
No
Does your child say what they want? Yes
No
RECEPTIVE
Does your child follow verbal directions without any visual cues? Yes
No
On a scale from one to ten, how much do you think your child understands?
1 words directions
2 Step
EXPRESSIVE
Does your child have any words? If yes, give examples.
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K cont.
Are the words the child has used in or out of context?
Does your child babble or combine sounds so that the combined sounds resemble some speech?
Are there any words that your child imitates? It so, please list:
What is the average length of your child’s utterances?
Are there problems with your child’s articulation or intonation of speech?
Can your child hold a conversation about a favorite topic for any length of time? Yes
No
If yes, how long?
L. Educational Background
Does your child attend school? Yes
No
(if no, skip to M.)
What type of classroom does your child attend? It this a DTT program?
How long has your child been attending school?
Does your child have an aide or shadow while attending school? (full or part time)? Yes
No
M. Other Current Services:
Is your child receiving other DIS services at this time? (e.g., behavior modification, speech, OT)? Please indicate
names and contact information
1.
2.
3.
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Child’s Current Schedule
TIME
7:00-7:30
7:30-8:00
8:00-8:30
8:30-9:00
9:00-9:30
9:30-10:00
10:00-10:30
10:30-11:00
11:00-11:30
11:30-12:00
12:00-12:30
12:30-1:00
1:00-1:30
1:30-2:00
2:00-2:30
2:30-3:00
3:00-3:30
3:30-4:00
4:00-4:30
4:30-5:00
5:00-5:30
5:30-6:00
MON.
TUE.
WED.
THUR.
FRI.
SAT.
SUN.
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Central California Autism Center
O. Goals and Objectives
Please list some goals that you would like your son or daughter to achieve by doing ABA therapy.
Are you willing to have the above information released for research purposes? Please initial.
Yes
No
Thank you for your time in completing the client intake form. Please return this the CCAC as soon as possible so
we may expedite the assessment and evaluation process.
Reference: Best Consulting Intake Form, Copyright 2002, Sacramento,Ca.
Steps to Independence, Fourth Edition. Copyright 2004 by Paul H. Brooks Publishing Co., Inc.
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Central California Autism Center
Community Social Skills
1.
Child will walk on sidewalk next to an adult
A. Always
B. With vocal reminders
C. With vocal and some physical prompting
D. Needs constant physical prompting to remain safe
2. Child will “stop” when asked by an adult
A. Always
B. With some physical prompting in certain situations
C. Requires full physical prompting to stop in community
3. Child will sit in an automobile with seatbelt buckled for 20 minutes at a time:
A. Always
B. Requires vocal reminders to sit, leave seatbelt on, and/or keep hands to self
C. Requires physical prompts to remain safe in automobile
4. Child is able to walk in a store with hands down
A. Always
B. With some vocal prompts
C. With some physical prompts
5. Chile is able to sit in a fast food restaurant and eat
A. With no or few prompts
B. With some vocal prompts
C. With some physical prompts
6. Child is able to fasten seatbelt
A. Independently
B. With vocal prompts
C. When adult models for child
D. With some physical assistance
E. Child cannot fasten seatbelt
7. Child is able to carry a small tray of food (no drink)
A. Independently
B. With vocal prompts
C. With some physical prompts
D. With full physical prompts
8. Child is able to make a simple purchase, consisting of giving the item to be purchased to cashier, giving money,
taking change and item:
A. Independently
B. With vocal prompts
C. With some physical prompts
D. With full physical prompts
9. While in community, child will respond to instruction “come here” when give by adult:
A. Always
B. Requires gestural prompts along with instruction
C. Requires some physical prompts
Resource: Best Consulting, 2002
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