ABA Development New Client Profile
Please fill this form out carefully in regards to the needs of your child. The information on this form is requested in order to help us better understand the individual needs of your child. ABA Development, Inc. will hold all information provided by you strictly confidential.
Parent Name *
Your answer
Email *
Your answer
Cell Phone Number *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Child's Full Name: *
Your answer
Nickname
Your answer
Birthday *
Your answer
Age *
Your answer
Sex: *
Current School Enrollment *
Your answer
Current Grade *
Your answer
Child's Diagnosis *
Your answer
Does your child have an IEP? If no, please indicate which formal assessment will be submitted. *
Submission of IEP or other formal assessment is required.
Please mark any services you are interested in. *
Required
Please list any other concerns/comments in regard to your child (i.e., specific social and behavioral needs). *
Your answer
How does your child communicate with you and others? *
Your child's interests: *
Your answer
Your child's dislikes: *
Your answer
Please list any specific sensory needs that staff should be aware of when working with your child. *
Your answer
Speech / Language Concerns *
Yes
No
N/A - nonverbal
Articulation: difficult to understand?
Expressive Language: express thoughts verbally?
Receptive Language: understands concept/command?
Academics *
Independent
Help Needed
No
Read
Write
Is your child toilet trained? *
Toileting *
Independent
Help Needed
Not Toilet Trained
Follow toilet routine
Void in toilet
Bowel movement in toilet
Wash/dry hands
Dressing *
Independent
Help Needed
Socks/shoes
Shirt
Pants/shorts
Tying Shoes
Feeding / Eating: *
Independent
Help Needed
Use of cup
Use of spoon
Use of fork
Use of straw
Chews and swallows food well
What are some common behaviors that staff should be aware of when working with your child? *
Your answer
When do these behaviors typically occur? *
Your answer
What interventions or methods can be used to minimize undesirable behaviors? *
Your answer
Please list any specific medical concerns in regard to your child. *
Your answer
Does your child have a risk of seizures? *
Is your child allergic to dogs? *
ABA Development has a therapy dog on site.
Please list any dietary restrictions and allergies: *
Your answer
Please list 2 social goals to focus on in group / private sessions: *
Your answer
Please list 2 academic goals to focus on in 1 on 1 academic tutoring sessions: *
Submit N/A response if not interested in academic tutoring,
Your answer
What ideas do you have that would help our staff fulfill the goals you listed above?
Your answer
Submit
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