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
Legal Name of Child*
First Name Middle Name Last Name
Today's Date*
Month Day Year
Gender*
Male Female
Child's Age*
Grade
Birth Date*
Month Day Year
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Parent/Guardian*
First Name Last Name
Occupation*
Phone Number*
E-mail*
Parent/Gaurdian
First Name Last Name
Occupation
Phone Number
E-mail*
Emergency Contact*
First Name Last Name
Phone Number*
Area Code Phone Number
Emergency Contact
First Name Last Name
Phone Number
Area Code Phone Number
Educational History
List all schools your child has attended.
School Name
Year(s) Attended
Grade(s)
School Name
Year(s) Attended
Grade(s)
School Name
Year(s) Attended
Grade(s)
List any other schools attended here. Include school name and years attended.*
Does your child have an IEP?
Yes No Undergoing testing
Date of last IEP meeting
Month Day Year
Household Information
List everyone who resides in the child's household, including ages.
How would you describe your parenting style?
Medical Information
Is your child taking any daily medication(s) or supplements?
Yes No No, but has taken in the past
Medication & dosage
When began
Medication & dosage
When began
Medication & dosage
When began
Describe your child's typical day/routine (e.g., 7:00 wake up, 7:30 breakfast, etc.). List specific wake up, nap, and bed times.
Problems and Solutions
What are some of your child's strengths?
What does your child like to do in his/her free time?
Provide a general overview of the behaviors of concern.
Are there times of the day when the behavior is more likely to occur?
Morning Afternoon Evening Before nap After nap Before bed Before meals
Are there specific activities when the behavior is more likely to occur?
Break in routine Toileting/diapering Before nap After nap Before bed Before meals When told "No" When given a direction When asked to do something non-preferred When corrected End of preferred activity Down time Playing with other kids/siblings
How frequently is the behavior occuring?
Multiple times a day Daily Several times per week Once a month
Are there circumstances that occur on some days and not others that make behavior more likely to occur?
Illness/allergies No medication/change in medication Hunger Lack of sleep Less quality time spent with one caregiver Change in caregiver Change in routine Home conflict Parties/social events
What have you tried already to try to manage the behavior?

Please rate how likely you are to use each of the strategies listed.

	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

What is your main goal for this consultation?
Date
Month Day Year
Signature
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Demographic Information

Educational History

Household Information

Medical Information

Problems and Solutions