BIOGRAPHICAL INFORMATION

Client Information:

Client First Name *

Client Last Name *

Client Date of Birth *

Gender *

Male

Female

Race/Ethnicity

Black

Hispanic

White

Native American

Asian/Pacific Islander

Other...

Parent/Guardian Information:

Name of parent(s)/guardian(s):

First Name *

Last Name *

2nd Parent/Guardian First Name

2nd Parent/Guardian Last Name

Language(s) spoken at home

Email *

Cell Phone

Home Phone

Work Phone

Preferred Communication Method

Phone

Email

Text

List who lives in the home

Name & Age (1):
Name & Age (2):
Name & Age (3):
Name & Age (4):
Name & Age (5):
Pets (if applicable)

CURRENT MEDICAL INFORMATION:

Primary Insurance Information:

Insurance Provider *

Insurance Policy ID # *

Group # *

Policy Holder's Name *

Policy Holder's Date of Birth

Policy Holder Relationship to Client *

Secondary Insurance Information (if applicable):

Insurance Provider

Insurance Policy ID #

Group #

Policy Holder's Name

Policy Holder's Date of Birth

Policy Holder's Relationship to Client

Medical Information:

Primary Care Physician (PCP)

PCP Telephone Number

PCP Facility Address

Other Medical Information/Exams:

*Please send us a diagnostic report completed by a MD, PhD in psychology or PsyD within the last 24 months

Developmental evaluation completed?

Yes

No

Diagnosis

Diagnosing Provider/Psychiatrist (Name/Credentials)

OT evaluation completed

Yes

No

Diagnosing Facility Name

Speech and language evaluation completed

Yes

No

Other evaluation and diagnosis tests completed? If so, list

Other Medical Information/Exams:

Allergies

Yes

No

Allergies (If yes, elaborate)

Dietary Restrictions

Yes

No

Dietary Restrictions: (If yes, elaborate)

Medications

Yes

No

Medication 1

Name
Dosage
Frequency

Medication 2

Name
Dosage
Frequency

Medication 3

Name
Dosage
Frequency

Medication 4

Name
Dosage
Frequency

SCHOOL INFORMATION:

School Special Support Services:

Does your child currently attend school?

Yes

No

Name of School District

Name of School

Grade Level and Placement Setting

Does your child have an active IEP?

Yes

No

Do you have a copy of the current IEP?

Yes

No

Does your child attend a regional center of early childhood program?

Yes

No

If yes, name of the regional center or early childhood program

Depending on your child’s needs, insurance regulations, and permission by the school district, a portion of the ABA services can be provided in your child’s school. Are you looking to possibly have some in in-school ABA services in conjunction with home-based services for your child?

Does your child have a current Behavior Intervention Plan (BIP)?

Yes

No

Are you interested in having PAL conduct a Functional Behavior Assessment (FBA) at your child’s school in order to develop and/or update/revise a current Behavior Intervention Plan for the school setting?

Other School Related Services (check all that apply):

Speech Therapy

Occupational Therapy

Physical Therapy

Other...

MAIN AREAS OF CONCERN:

Regarding receiving ABA services, what are the main areas of concern you would like to see an increase/decrease in with your child?

Does your child have any previous ABA experience?

Yes

No

How long was prior ABA experience?

Behavioral Reasons for Referral

Health risk

Self-injurious Behaviors

Aggression toward others

Destruction of Property

Stereotyped/repetitive Behaviors

Elopement

Severe Disruptive Behavior

Social skills

Mouthing/Pica

Transitions/Lack of flexibility

Other...

Client’s form of communication

Vocal Verbal with delays

Verbally Age Appropriate

Non-vocal verbal (gestures such as pulling hand and/or pointing)

Picture Exchange Communication (PECS) or other visual supports

Communication device

Other...

CHILD AVAILABILITY FOR THERAPY SESSION:

Monday Availability

8:00am

9:00am

10:00am

11:00am

12:00pm

1:00pm

2:00pm

3:00pm

4:00pm

5:00pm

6:00pm

7:00pm

Tuesday Availability

8:00am

9:00am

10:00am

11:00am

12:00pm

1:00pm

2:00pm

3:00pm

4:00pm

5:00pm

6:00pm

7:00pm

Wednesday Availability

8:00am

9:00am

10:00am

11:00am

12:00pm

1:00pm

2:00pm

3:00pm

4:00pm

5:00pm

6:00pm

7:00pm

Thursday Availability

8:00am

9:00am

10:00am

11:00am

12:00pm

1:00pm

2:00pm

3:00pm

4:00pm

5:00pm

6:00pm

7:00pm

Friday Availability

8:00am

9:00am

10:00am

11:00am

12:00pm

1:00pm

2:00pm

3:00pm

4:00pm

5:00pm

6:00pm

7:00pm

Weekend options depend on the Behavior Therapist’s availability. Looking for services on weekends?

Yes

No

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