Welcome to ACES behavioral services!

Transcription

1 Welcome to ACES behavioral services! In order for us to get to know the needs of our clients and client families, we ask that you fill out the following intake form as thoroughly as you can. Before our first meeting we will need the following paperwork in addition to the ACES intake forms: Letter of medical necessity, if required by funding source Recent educational/psychological evaluations or diagnostic reports (from within the past two years) A completed behavioral intake form Most recent IEP/ISP/IFSP/ or 504 plan Most recent Behavior Intervention Plan Progress or discharge reports from current/previous provider(s) Logistics What type of ABA program are you interested in: Comprehensive (addressing skill acquisition and behavior reduction) Early intervention / Early learning Focus on behavior reduction Focus on skill acquisition Focus on activities of daily living Focus on coping/emotional regulation Focus on social skills Parent or Caregiver training What is the maximum hours per week you wish to receive services? What is the minimum hours per week you wish to receive services? Where do you wish to receive services? In-home In-office Community-based (434) , Videophone (434) , Fax (434) Page 1 of 14

2 Intake Contents Welcome to ACES behavioral services! 1 Logistics 1 Profile 3 Caregivers/relatives with regular contact with client 3 Medical Information 4 Evaluations and Services 5 Activities of Daily Living 7 Behaviors of Concern 7 Behavior 1: 7 Behavior 2: 8 Behavior 3: 9 What level of supervision is required? 10 Communication Skills 11 Skill Acquisition 11 Skill 1: 11 Skill 2: 12 Skill 3: 12 Preferences 12 Aversions 13 Expectations/Narrative 13 (434) , Videophone (434) , Fax (434) Page 2 of 14

3 Profile Date: Client name: Client date of birth: Client Gender: M F Client Current Age: Form completed by: Home Language: Relationship to client: Spoken or Signed? Primary caregivers: Relationship to client: Biological parent(s) Foster parent(s) Sibling Adoptive parent(s) Grandparent(s) Other: Caregivers/relatives with regular contact with client 1 Primary caregiver name: Relationship to client: Address: Home phone: Cell phone: Lives with client? No Full-time Shared-time Prefered method of communication: 2 Primary caregiver name: Relationship to client: Address: Home phone: Cell phone: Lives with client? No Full-time Shared-time Prefered method of communication: (434) , Videophone (434) , Fax (434) Page 3 of 14

4 3 Caregiver name: Relationship to client: Address: Home phone: Cell phone: Lives with client? No Full-time Shared-time Prefered method of communication: 4 Caregiver name: Relationship to client: Address: Home phone: Cell phone: Lives with client? No Full-time Shared-time Prefered method of communication: Who else lives in the home? Home A Home B Medical Information Primary diagnosis: Date of diagnosis: Who gave diagnosis: Please list all other diagnoses (developmental, psychiatric, medical): (434) , Videophone (434) , Fax (434) Page 4 of 14

5 Does the client have any of the following: ACES Behavioral Intake Form Ye s No Yes No Seizures Hearing loss Visual impairment Wheelchair Repetitive behaviors / stereotypy Hearing aids Cochlear implant Walker Other: Current medications Name Dosage Purpose Allergies: Diet restrictions/preferences: Evaluations and Services Please list all evaluations and enclose copies of evaluation reports Date of Evaluation Provider Name Provider title/ Area of specialty Reason for evaluation (434) , Videophone (434) , Fax (434) Page 5 of 14

6 Does the client currently attend school, daycare, or a day treatment program? Yes No Is there an active IEP? Yes No School/program name: Contact name: Address: Contact number: Contact Please list all current and past clinical services (SLP/OT/PT etc.) Name of Service Provider Hours per week Current / Past Current Current Current Current Current Current Past Past Past Past Past Past Past and current alternative therapy / intervention Gluten/Casein Free Diet Current Past Sensory integration Current Past Floortime Current Past Son-Rise Current Past Rapid Prompting Method Current Past Hyperbaric Chamber Treatment Current Past Chelation Current Past (434) , Videophone (434) , Fax (434) Page 6 of 14

7 Other: Current Past Activities of Daily Living Does the client feed him/herself independently? Yes No Does the client drink from a bottle or sippy cup? Yes No Is the client potty trained? Yes No Describe eating and drinking patterns and issues of concern: Describe sleeping patterns and issues of concern: Describe toileting patterns and issues of concern: Describe independent dressing skills and issues of concern: Behaviors of Concern Does the client engage in any of the following behaviors? Ye s No Yes No Physical aggression Property destruction Eloping (running away) Tantrums Repetitive behaviors / stereotypy Verbal outbursts Self injurious behavior Self stimulatory behavior What are the top 3 behaviors you hope to address? Behavior 1: (434) , Videophone (434) , Fax (434) Page 7 of 14

8 Description: Examples: How often does the behavior occur? (100x a day? 10x a week?) Settings in which the behavior occurs (home/school/community): When is the behavior likely to occur? How do people (staff, parents, etc.) typically respond to this problem behavior? Which of the following procedures have been used to address the problem behavior?: Restraint: Yes No Describe: Protective Equipment (e.g., helmet, gloves): Yes No Describe Positive reinforcement procedures: Yes No Describe Time out: Yes No Describe Behavior 2: (434) , Videophone (434) , Fax (434) Page 8 of 14

9 Description: Examples: How often does the behavior occur? (100x a day? 10x a week?) Settings in which the behavior occurs (home/school/community): When is the behavior likely to occur? How do people (staff, parents, etc.) typically respond to this problem behavior? Which of the following procedures have been used to address the problem behavior?: Restraint: Yes No Describe: Protective Equipment (e.g., helmet, gloves): Yes No Describe Positive reinforcement procedures: Yes No Describe Time out: Yes No Describe Behavior 3: (434) , Videophone (434) , Fax (434) Page 9 of 14

10 Description: Examples: How often does the behavior occur? (100x a day? 10x a week?) Settings in which the behavior occurs (home/school/community): When is the behavior likely to occur? How do people (staff, parents, etc.) typically respond to this problem behavior? Which of the following procedures have been used to address the problem behavior?: Restraint: Yes No Describe: Protective Equipment (e.g., helmet, gloves): Yes No Describe Positive reinforcement procedures: Yes No Describe Time out: Yes No Describe What level of supervision is required? Constant supervision by two adults 2:1 Constant supervision by one adult 1:1 (434) , Videophone (434) , Fax (434) Page 10 of 14

11 Small group Large group Completely independent Can be left alone for brief periods: Yes No Needs constant monitoring, but can work in a group: Yes No Communication Skills Skill Consistently Sometimes Never Speaks/Signs freely and easily Speaks/Signs mainly in phrases Uses single words/signs Uses modified signs (not Deaf/HOH) Uses gestures Communicates with pictures Understands simple questions Follows simple instructions Verbally imitates Physically imitates Name of communication device used (if applicable): Skill Acquisition What are the top 3 skills you would like the client to learn? Skill 1: Description: Examples: (434) , Videophone (434) , Fax (434) Page 11 of 14

12 (434) , Videophone (434) , Fax (434) Page 12 of 14

13 Skill 2: Description: Examples: Skill 3: Description: Examples: Additional skills: Preferences What items, activities, places, or environments does the client prefer? Social interaction With caregivers With peers With adults? Types of social interaction (examples include praise, fist bump, hugs, etc.) Favorite food Favorite toys Favorite activities Physical activities Other (434) , Videophone (434) , Fax (434) Page 13 of 14

14 Aversions What items, activities, places, or environments does the client not like? Expectations/Narrative Describe your goals for the client: (434) , Videophone (434) , Fax (434) Page 14 of 14