Client Intake
Marcee Brown, MS, BCBA
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Mother's Name
First Name
Last Name
Mother's Occupation
Mother's Address
Mothers's Date of Birth
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Mother's Phone Number
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Phone Number
Mother's E-mail
example@example.com
Please describe your typical work schedule.
Please indicate if there are any mental or behavioral health issues within the family (for example, ADHD in biological mother)
Father's Name
First Name
Last Name
Father's Occupation
Father's Date of Birth
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Year
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Father's Phone Number
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Phone Number
Father's E-mail
example@example.com
Please describe your typical work schedule.
Legal Guardian
First Name
Last Name
Legal Guardian's Occupation
Legal Guardian's Date of Birth
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Legal Guardian's Phone Number
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Area Code
Phone Number
Legal Guardian's E-mail
example@example.com
Please describe your typical work schedule.
Please indicate if there are any mental or behavioral health issues within the family (for example, ADHD in biological mother)
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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Area Code
Phone Number
E-mail
Psychiatrist
Phone Number
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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?
Please Select
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?
Please Select
No
Yes
Has your child ever shown aggression towards others?
Please Select
No
Yes
Has your child ever destroyed property?
Please Select
No
Yes
Has your child ever injured him or herself?
Please Select
No
Yes
Has your child ever run away?
Please Select
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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Submit
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