BEHAVIORAL SERVICES – INTAKE FORM BEHAVIORAL SERVICES – INTAKE FORM GENERAL INFORMATIONClients Name(Required) Date(Required) MM slash DD slash YYYY Gender(Required)GenderMaleFemaleAddress(Required) Primary Diagnosis(Required) Diagnosing Doctor(Required) Diagnosing Date(Required) MM slash DD slash YYYY Insurance Carrier(Required) Member ID(Required) PARENT AND/OR GUARDIANName(Required) Name Phone(Required)PhoneEmail(Required) Email ATTACHMENTS: ATTACH ANY DIAGNOSTIC OR PSYCHOLOGICAL EVALUATIONS. ANY OTHER RECORDS THAT WOULD ASSIST BEHAVIORAL SERVICES.MEDICATION(S): PLEASE IDENTIFY TYPE, DOSAGE, AND TIME OF ANY MEDICATION PARTICIPANT IS CURRENTLY TAKING:TYPE TYPE TIME REASON TYPE TYPE TIME REASON TYPE TYPE TIME REASON TYPE TYPE TIME REASON TYPE TYPE TIME REASON TYPE TYPE TIME REASON GOALS AND OBJECTIVES: BASED ON YOUR KNOWLEDGE OF THE PERSON, WHAT GOALS AND / OR OBJECTIVES DO YOU THINK WOULD HELP THEM TO LEAD A MORE INDEPENDENT LIFE? YOUR INPUT WOULD BE MOST APPRECIATED. WE WILL WORK WITH THE PARTICIPANT IN THE FOLLOWING AREAS DURING BEHAVIORAL SERVICES TO HELP MEET THESE GOALS AND OBJECTIVES:LANGUAGE SKILLS:(Required)SOCIAL SKILLS:(Required)COGNITIVE SKILLS:(Required)COPING AND SELF-MANAGEMENT SKILLS:(Required)INDEPENDENT LIVING SKILLS:(Required)ADDITIONAL INFORMATION:(Required)Consent(Required) I UNDERSTAND THAT I AM ATTESTING TO THE FOLLOWING(Required)-INSURANCE BEING PULLED AND UTILIZED -I AM THE LEGAL GUARDIAN FOR THIS CLIENT -I UNDERSTAND RESERVE THE RIGHTS TO PULL MY CHILD FROM SERVICES WITHOUT IT IMPACTING FUTURE SERVICES -I AM CONSENTING TO MY CHILD PARTICIPATING IN APPLIED BEHAVIOR ANALYSIS THERAPYPRINT NAME(Required) RELATIONSHIP TO PARTICIPANT(Required) SIGNATURE(Required) DATE(Required) MM slash DD slash YYYY CAPTCHA
