ABA Intake Form Parent or Guardian First Name:* Parent or Guardian Last Name:* Phone Number:*Email Address:* Child's Name:* What led you to seek Behavior Therapy for your child?What does the behavior look/sound like? Please answer the following questions regarding Aggression to Others. Where does the behavior occur? Are people present when it occurs? What time of day/routine? How often does the behavior occur? Please answer the following questions regarding Self-Injury. Where does the behavior occur? Are people present when it occurs? What time of day/routine? How often does the behavior occur? Please answer the following questions regarding Eating/Feeding Issues. Where does the behavior occur? Are people present when it occurs? What time of day/routine? How often does the behavior occur? Please answer the following questions regarding Non-Compliance. Where does the behavior occur? Are people present when it occurs? What time of day/routine? How often does the behavior occur? Please answer the following questions regarding Property Destruction. Where does the behavior occur? Are people present when it occurs? What time of day/routine? How often does the behavior occur? Please answer the following questions regarding Escaping. Where does the behavior occur? Are people present when it occurs? What time of day/routine? How often does the behavior occur? Please answer the following questions regarding Acting Out. Where does the behavior occur? Are people present 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?
