ABA Therapy Intake Form Parent/Guardian First Name:*Parent/Guardian Last Name:*Primary Phone Number:*Alternate Phone NumberEmail Address:* Child’s Name:* What led you to seek Behavior Therapy for your child?What does the behavior look/sound like?Behavioral IssuesPlease complete the chart below for each behavior of concern listed.Aggression to OthersWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur?Self-InjuryWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur?Eating/Feeding IssuesWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur?NoncomplianceWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur?Property DestructionWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur?EscapingWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur?Acting OutWhere does behavior occur?People there when it occurs?What time of day/routine?How often does the behavior occur? Are there any warning signs that the child displays that let you know the behavior(s) might occur (e.g. changes in mood, pacing, appears agitated, etc.)?What tends to trigger the identified behavior(s)? What is typically happening when the behavior(s) occur?What would you like to see happen in place of the behaviors described above?
