Client Intake Form for Behavioral Consulting

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 NameMiddle NameLast Name
Today's Date
MonthDayYear
Gender
Child's Age
Grade
Birth Date
MonthDayYear
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Parent/Guardian
First NameLast Name
Occupation
Phone Number
Format: (000) 000-0000.
E-mail
Parent/Gaurdian
First NameLast Name
Occupation
Phone Number
Format: (000) 000-0000.
E-mail
Emergency Contact
First NameLast Name
Phone Number
Area CodePhone Number
Emergency Contact
First NameLast Name
Phone Number
Area CodePhone 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?
Date of last IEP meeting
MonthDayYear
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?
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?
Are there specific activities when the behavior is more likely to occur?
How frequently is the behavior occuring?
Are there circumstances that occur on some days and not others that make behavior more likely to occur?
What have you tried already to try to manage the behavior?

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

Rows	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
MonthDayYear
Signature
Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Demographic Information

Medical Information

Problems and Solutions