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Families

Parent Intake Questionnaire

This questionnaire helps our Board Certified Behavior Analyst prepare for your child’s first assessment. It takes about 20 to 30 minutes.

Before you start

  • There are no right or wrong answers. Describe your child as they are on a typical day.
  • Skip any question that does not apply or that you prefer to discuss in person.
  • Everything you share is confidential and protected under HIPAA.
  • This form is not a diagnosis and does not replace the assessment.
  • If your child is in immediate danger, call 911. Do not use this form for emergencies.

Questions marked * are needed to send the form.

Online sending is not switched on yet. You can fill in the questionnaire here and your answers will stay on this device, but to send it please call our office at (202) 211-5111.

1.About this form

Do you need an interpreter?

Who lives in the home with the child?

Person 1
Person 2
Person 3
Person 4

How did you hear about us?

2.Diagnosis and previous services

Do you have the written diagnostic report?

Has your child received ABA therapy before?

If yes:

Other services, now or in the past(check all that apply)

Speech therapy
Occupational therapy
Physical therapy
Feeding therapy
Early Intervention (birth to 3)
Counseling or psychology
Other:

3.Birth and early development

Pregnancy and birth

weeks

At about what age did your child first do the following?Write “not yet” where it applies.

Sit without support
Crawl
Walk alone
Babble
Say first words
Combine two words
Point to show you something
Respond to their name

Has your child ever lost a skill they once had (words, eye contact, play)?

4.Health

Medical conditions

Allergies (food, medication, environmental)

Is epinephrine (EpiPen) prescribed?

Current medications

Medication 1
Medication 2
Medication 3

Hearing tested?

Vision tested?

Does your child wear glasses, hearing aids, or use other equipment?

5.Communication

How does your child mainly communicate?(check all that apply)

About how many words does your child use on their own?

Does your child…

Respond when you call their name
Ask for things they want (words, signs, or pictures)
Follow a simple instruction (“come here”, “sit down”)
Follow a two-step instruction (“get your shoes and bring them”)
Answer simple questions (“What is your name?”)
Say “no” or refuse in an appropriate way
Repeat words or phrases from others or from videos
Tell you when something hurts

6.Social skills and play

Does your child…

Make eye contact
Smile back or share enjoyment with you
Bring or show you things just to share them
Copy what you do (clapping, waving)
Show interest in other children
Play next to other children
Play with other children
Take turns
Play pretend (feed a doll, drive a toy car)
Play alone for 5 minutes or more
Handle changes in routine without major distress

7.Behaviors of concern

Many children we see have some of these behaviors. Honest answers help us keep your child safe and plan the right support.

For each behavior, check how often it happens.

Tantrums or meltdowns (crying, screaming, dropping to the floor)
Hitting, kicking, biting, or scratching others
Hurting self (head banging, biting or hitting self)
Running away or leaving a safe area
Throwing or breaking things
Refusing instructions
Putting non-food items in the mouth or eating them
Climbing or other dangerous behavior
Repetitive movements or sounds that get in the way of daily life
Smearing stool or playing with it
Undressing in public
Other:

For the behavior that worries you most:

What usually happens right before?

Has anyone been injured?

Safety

Has your child ever left the home, school, or a caregiver without permission?

Does your child understand danger (traffic, hot surfaces, water, heights)?

8.Toileting

Where is your child with toilet training?

What does your child wear?

Daytime

Nighttime

Urine accidents during the day
Bowel accidents during the day
Wetting at night

Does your child…

Tell you or show you they need to go
Notice or mind being wet or soiled
Sit on the toilet when asked
Stay dry for 2 hours or more
Pull pants down and up
Wipe
Flush and wash hands

Is your child afraid of the toilet, flushing, or public restrooms?

Constipation or holding stool?

Has a doctor been consulted about it?

Please send a change of clothes, and diapers or pull-ups if used, to every session.

9.Eating

How does your child eat?

How many different foods will your child eat?

Check any that apply

10.Sleep

Naps

Check any that apply

11.Daily living skills

Skill

Dressing
Undressing
Putting on shoes
Washing hands
Brushing teeth
Bathing
Tolerating haircuts and nail trimming
Tolerating doctor and dentist visits

12.Sensory

Is your child bothered by any of these?

Does your child seek out any of these?

Does your child seem to feel pain less than other children?

13.School and daily schedule

Does your child attend school, preschool, or daycare?

IEP or 504 plan

14.What your child enjoys

We use the things your child loves to make learning fun.

May we offer food as a reward during sessions?

15.Your goals

What are the three most important things you would like your child to learn or change in the next 6 months?

Which parts of the day are hardest?

Parent training is part of ABA therapy.

16.Availability

Our hours are Monday to Friday, 8:00 AM to 7:00 PM. Check every time your child could attend.

Morning (8 AM to 12 PM)
Afternoon (12 PM to 4 PM)
Late afternoon (4 PM to 7 PM)

17.Anything else

Signature

Type your full name.

Your answers are saved on this device as you go, until you send the form. On a shared computer? .