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 *
Email *
Cell Phone Number *
Home Address *
City *
State *
Zip Code *
Child's Full Name: *
Nickname
Birthday *
Age *
Sex: *
Current School Enrollment *
Current Grade *
Child's Diagnosis *
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). *
How does your child communicate with you and others? *
Your child's interests: *
Your child's dislikes: *
Please list any specific sensory needs that staff should be aware of when working with your child. *
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? *
When do these behaviors typically occur? *
What interventions or methods can be used to minimize undesirable behaviors? *
Please list any specific medical concerns in regard to your child. *
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: *
Please list 2 social goals to focus on in group / private sessions: *
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,
What ideas do you have that would help our staff fulfill the goals you listed above?
Submit
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