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Autism Center of Sauk Valley Intake Form
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* Indicates required question
Email
*
Your email
Recipient's name
*
Your answer
Name of person filling out this form
*
Your answer
Phone number
*
Your answer
Other parent/guardian's phone number, if applicable
Your answer
Email address
*
Your answer
Other parent/guardian's email address, if applicable
Your answer
Your relationship with the recipient
*
Parent
Guardian
Other:
Are you authorized to consent for this person's healthcare?
*
Yes
No
Date of birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Are the parents divorced or separated?
*
Yes
No
N/A
If so, please describe the allocation of parenting time and decision-making responsibilities
Your answer
First parent's name
*
Your answer
First parent's address
*
Your answer
Second parent's name
Your answer
Second parent's address
Your answer
Names and ages of siblings
Your answer
Who else lives in the household?
Your answer
List any other significant people in the recipient's life who do not live with him or her
Your answer
Pets in the home
Your answer
Primary language
*
English
Other:
Diagnoses
*
Your answer
Name of diagnosing provider
*
Your answer
Date of diagnosis
*
MM
/
DD
/
YYYY
Does the recipient have a primary care physician (PCP)?
*
Yes
No
Name and phone number of PCP
Your answer
May we contact the PCP to collaborate?
*
Yes
No
N/A
Has the recipient ever been seen by an Occupational Therapist, Speech and Language Therapist, Psychiatrist, Psychologist, Special Educator, or other mental health counselor?
*
Yes
No
Provide the name of the provider, specialty, dates of care, purpose of care, and results, if applicable
Your answer
Do we have permission to contact the provider(s) to collaborate?
*
Yes
No
N/A
Other:
Has the recipient received ABA services in the past?
*
Yes
No
Explain
Your answer
Do we have permission to contact the previous provider?
*
Yes
No
N/A
Other:
Is the recipient currently attending school?
*
Yes
No
Other:
Provide the name, district, and grade, if applicable
Your answer
Is the recipient receiving special services or accommodations at school?
*
Yes
No
Not applicable
If yes, explain what type (IEP, IFSP, 504 Plan, etc)
Your answer
What medications and dosages are being taken, if any?
Your answer
Does the recipient have any allergies?
*
Your answer
What does the recipient like? (Favorite activities, food, interests/topics, sensory)
*
Your answer
What does the recipient dislike? (Aversions)
*
Your answer
Reason for seeking ABA services (concerns)
*
Your answer
What are the recipient's strengths?
*
Your answer
Specific areas of concern
*
Cognitive
Motor
Behavior
Language
Social
Peer interaction
Play/leisure
Self-help (dressing, hygiene, toileting, etc)
Dietary
Academics
Executive functioning (organization, flexibility, attention, etc)
Other:
Required
Describe important cultural practices, rituals, traditions or beliefs we should be aware of
Your answer
Were there any complications during the recipient's pregnancy or birth?
*
Yes
No
Unsure
Explain
Your answer
Is there a family history of autism spectrum disorder?
*
Yes
No
Explain
Your answer
Is there a family history of mental illness?
*
Yes
No
Explain
Your answer
Are there medications caregivers take that impact session delivery or caregiver involvement?
*
Yes
No
Explain
Your answer
Does the recipient and/or family member have a history of substance abuse, including tobacco?
*
Yes
No
Explain
Your answer
Has the recipient been identified to be at risk of harm to self and/or others, including suicide and/or homicide?
*
Yes
No
Explain
Your answer
Does the recipient have any history of trauma or abuse?
*
Yes
No
Explain
Your answer
Has the recipient ever been hospitalized for a physical illness or accident?
*
Yes
No
Explain
Your answer
Has the recipient ever been hospitalized for a mental illness?
*
Yes
No
Explain
Your answer
Has the recipient had any major illnesses or surgeries?
*
Yes
No
Explain
Your answer
Does the recipient have vision or hearing problems?
*
Yes
No
Explain
Your answer
List top three goals/areas you'd like to see improve in the next 6 months
*
Your answer
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