Client Intake Form for Behavioral Consulting

Client Intake Form for Behavioral Consulting

This form is to be completed by the parent/guardian of the child for behavioral consulting. This is designed to collect child information like their education, household, medical information and their behavior problems. If you're a social consultant, this form would help you reach out the parents and help their concerns. Form Preview
  • Client Intake Form

    All information given is strictly confidential. At no given point is information disclosed or shared without client’s written consent. You may skip any questions you do not feel comfortable answering. 

  • Demographic Information

  •  -  - Pick a Date
  •  -
  •  -
  • Educational History

  • List all schools your child has attended. 

  •  -  - Pick a Date
  • Household Information

  • Medical Information

  • Problems and Solutions

  •   Highly Unlikely Unlikely Neutral Likely Very Likely
    Let situation go
    Take away a privilege
    Asking an additional chore
    Take away a tangible/object
    Send to room
    Reason with child
    Send to time out
  •  -  - Pick a Date
  • Clear
  • Should be Empty:
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