Intake Form (Questionnaire)

Intake Questions (open-ended)

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Today's Date *

Phone *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Child/Adult Child First Name *

Child/Adult Child Last Name

Email *

Child/Adult Child's Date of Birth *

Insurance Co. *

Member Id# *

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? *