Initial Intake Form - School Age This intake form is for families with children between the ages of 6-18 years. Email Child's full name Child's full name Date of birth Parent/Guardian Name Address Contact telephone number Where does the child currently live? Both parents/guardians Mother Father Grandparent Foster care Others Developmental History Was the infant born at full term? Yes No Other Were there any complications? If so, describe. Yes No Others Did you have any concerns about your child's development during the first three years? Is there any other important information related to your child's developmental history? Medical Information Primary Diagnosis Secondary diagnosis Please upload your child's diagnostic report(s). If you are unable to do so using this form, please email to tana@thebehaviourchangeclinic.ca Does your child currently take medications? If so, please provide the name of the medication. Other Current Services Is your child currently receiving any of the following services? Speech and Language therapy Occupational Therapy Behaviour Consultation None Others What school does your child currently attend? What grade is your child in? What type of program is your child in? Full inclusion Partial inclusion/resource base Resource Room/BASES Life skills Others What types of support does your child receive at preschool? EA/1:1 ABA-SW Resource room/IST Small group/LST Others This section is designed to obtain preliminary information about your child that will help to inform assessment. How does your child get his/her primary needs met? Vocal/Verbally Picture exchange Sign None Others How many times per day does your child make requests? A few Several Many times/fluent None Others Does your child consistently follow 1-2 step instructions? Yes No Others Does your child consistently follow complex (3-4 step) instructions? Yes No Others This section is designed to obtain preliminary information about your child that will help to inform assessment. Does your child initiate conversation with others? Describe. What are your child's favourite toys/activities? Does your child engage in pretend play? Describe. Does your child engage in imaginary play with objects? Describe. This section is designed to obtain preliminary information about your child that will help to inform assessment. Is your child fully toilet trained? Yes No Others Do you have any concerns regarding toileting? Does your child have any sleeping problems? If so, describe. Does your child have any eating problems? If so, describe. This section is designed to obtain preliminary information about your child that will help to inform assessment. Please rate your concerns related to aggression towards self 1 2 3 4 5 Please rate your concerns related to aggression towards others 1 2 3 4 5 Please rate your concerns related to property destruction 1 2 3 4 5 Please rate your concerns related to refusal behaviours 1 2 3 4 5 This section is designed to obtain preliminary information about your child that will help to inform assessment. Please rate your child's ability in Reading Below Average Average Above Average Please rate your child's ability in Writing Below Average Average Above Average Please rate your child's ability in Math Below Average Average Above Average Date of last psychoeducational assessment Not had one completed Others Please use this opportunity to create a "wish list" of skills you would like your child to learn. Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Send
