Client Intake
Marcee Brown, MS, BCBA
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Mother's Name
First Name
Last Name
Occupation
Please describe your typical work schedule.
Father's Name
First Name
Last Name
Occupation
Please describe your typical work schedule.
PREGNANCY & BIRTH: Gestation-Was the pregnancy & delivery normal? Please explain special circumstances or any other imformation you deem necessary.
MEDICAL: Does your child have a diagnosis? If so,what is it, when was it made and by whom?
Does your child have allergies? If so, please explain.
Does your child have any other medical concerns not previously listed? If so, please explain.
Psychologist
Phone Number
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Area Code
Phone Number
E-mail
Pediatrician
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Phone Number
E-mail
Psychiatrist
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Area Code
Phone Number
E-mail
Neurologist
Phone Number
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Area Code
Phone Number
E-mail
Teacher
Phone Number
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Area Code
Phone Number
E-mail
Other: Please Specify Relationship
Phone Number
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Area Code
Phone Number
By placing a check next to the following providers you give Marcee Brown consent to contact them.
Pediatrician
Psychologist
Psychiatrist
Neurologist
Teacher
Other
List medications CURRENTLY being taken, start date of medication, purpose, & dosage (include herbal supplements, nutritional and/or vitamin supplements, & enzymes if applicable).
Previous medications, start & end date, purpose, & dosage.
DIET: Is your child on a restricted diet?
No
Yes
How long has your child been on the diet?
What dietary eliminations are currently being used (gluten, milk, yeast, soy, corn, eggs, others)?
Is your child on an elimination and rotation diet? If so, please explain.
BEHAVIOR: Has your child ever had prior behavior intervention?
No
Yes
Has your child ever shown aggression towards others?
No
Yes
Has your child ever destroyed property?
No
Yes
Has your child ever injured him or herself?
No
Yes
Has your child ever run away?
No
Yes
What is the average number of hours of sleep your child gets each night?
SCHOOLS, PROGRAMS, & THERAPIES (include in-home services). Please include past & current services listing the Name,Service Provided, Dates Attended,Location, Evaluations Conducted & Dates, as well as a Phone number.
Do you have pets in the house? If so please disclose.
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Please provide any additional information that may be beneficial to know about your child or family.
Mother:I want to be involved in treatment (1=least, 5most).
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Father: I want to be involved in treatment (1=least, 5=most).
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