Intake Form (Questionnaire) Intake Questions (open-ended) Intake Questions (open-ended) Page 1Page 2Page 30% Complete1 of 3 Basic Information Date * Phone * First Name * Last Name Email * Date of Birth * Insurance Insurance Co. * Member Id# * Preferred/non-preferred activities/environments/people 1.What are your son/daughter’s most preferred activities? * 2.What are your son/daughter’s most preferred food items/drinks? * 3. What are your son/daughter’s most preferred items/tangibles? * 4. Does your son/daughter have preferred people or family members? * 5. Are there activities/items/food that your son/daughter dislike? 6. Are there people that your son/daughter do not prefer? * 7. Are there environments or stimulus (noises etc.) that your son/daughter cannot tolerate or that lead to problem behaviors? * Next If you are human, leave this field blank.
