HBA Intake Form

Full Name *

First Name Last Name

Date of Birth

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Area Code Phone Number

Age

Diagnosis (if applicable)

Mother/Guardian's Name:

First Name Last Name

Mother/Guardian's Occupation:

Mother/Guardian's Address (if different):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mother/Guardian's Email

example@example.com

Father/Guardian's Name:

First Name Last Name

Father/Guardian's Occupation:

Father/Guardian's Address (if different):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Father/Guardian's Email

example@example.com

Marital status of parents:

Married Separated Divorced Single

Who has custody of the child?

Mother Father Both parents Grandparents

Was the child adopted?

Yes No

Please select insurance

If the client has siblings, please list them below:

Family history of developmental disability or mental illness?

Yes No

If yes, list the condition(s) and relation to client:

School Information:

School district:

Name of School:

Grade: Date enrolled:

Date of most recent IEP (if applicable):

Placement

General Education (no IEP) General Education (Inclusion with IEP) Pull-out (collaborative model) Self-contained

Days and times of attendance:

Related Service #1

Hours per week

Progress observed

Agency Phone Number

Area Code Phone Number

May we contact?

Yes No

Related Service #2

Hours per week

Progress observed

Agency Phone Number

Area Code Phone Number

May we contact?

Yes No

Related Service #3

Hours per week

Progress observed

Agency Phone Number

Area Code Phone Number

May we contact?

Yes No

Additional Services? List them here.

Doctor/Medication information:

Medication list

Are there concerns about your child's hearing?

Yes No

Hearing assessment conducted?

Yes No

Are there concerns about your child's vision?

Yes No

Vision assessment conducted?

Yes No

Any childhood illnesses?

At what age did your child...

Does your child currently sleep through the night?

At what age did you suspect problems in your child's development?

Has your child exhibited any loss of skills in any areas?

If so, please explain:

Describe how your child plays:

Does your child play independently?

Yes No

If so, how long? With what items/toys?

Does your child play with toys appropriately?

Yes No

Explain:

Does your child attempt to involve others in play?

Yes No

Explain:

Does your child engage in interactive play with other children?

Yes No

Explain:

Does your child engage in pretend play?

Yes No

Explain:

Describe your child's language:

Does your child respond in some way when his/her name is called?

Yes No

Describe your child's ability to imitate sounds, words, phrases:

Describe how your child communicates what s/he wants:

How consistently does your child...

	Always	Most of the time	Seldom	Never
Follow simple directions
Make eye-contact
label items/events/actions
Answer "Wh" questions
Engage in verbal exchange with others

Can your child perform the following skill appropriately for their age:

	Yes	No	N/A
Identify Numbers
Identify Letters
Complete a puzzle
Match items
Sort colors and shapes
Stack blocks
Draw
Write numbers/letters
Identify people

Motor skills: Can your child...

	Yes	No
Imitate gestures (e..g, clapping, waving)
Imitate gestures using objects (e.g., banging on a drum)
Imitate fine motor gestures

Describe your child's general gross motor abilities:

Describe your child's general fine motor abilities:

Self Help Skills: Is your child...

	Yes	No
Toilet Trained
Able to feed self
Able to clean up independently

Have you observed your child eimt any of the following behaviors? If yes, please explain. If not, please fill in N/A.

Self stimulatory behaviors (examples: vocal sounds, flapping hands, lining up objects). If yes, please explain:

Self-injurious behaviors (examples: banging head on hard objects, eye-poking). If yes, please explain:

Unsafe behaviors to self (examples: running away, climbing furniture). If yes, please explain:

Unsafe behaviors to others (examples: hitting, throwing objects). If yes, please explain:

Ritualistic/obsessive behaviors (examples: wearing same clothes every day, talks only about one topic). If yes, please explain:

Please list/explain any other behaviors of concern:

Please state your short term goal(s) for your child:

Please state your long term goal(s) for your child:

How did you hear about us?

Google Search Facebook Rocket City Moms Ad Referral

Intake Form

Client Information

Family Information

Family Information

Family Information

Academic Information

Related Services

Medical Information

Developmental History

Social and Play Skills

Communication Skills:

Behaviors of Concern

Goals