INITIAL INTAKE INTERVIEW

CLIENT INFORMATION
DEMOGRAPHIC INFORMATION

Patient’s Name: Patients Date of Birth:

Patient’s Gender: Current Grade:

Current School: Does the Patient have an IEP?:

Mother’s Name: Mother’s Phone:

Mother’s Email: Does the Patient live with Mother?:

Father’s Name: Father’s Phone:

Father’s Email: Does the Patient live with Father?:

Who will be the Primary Contact Person regarding Patient’s Medical Treatment?:

Other Caregivers (include name, relation, and contact information):

Patient’s Physical Address:

City: State: Zip:

Mailing Address:

City: State: Zip:

DIAGNOSTIC INFORMATION

Primary Care Physician:

Primary Diagnosis: Date of Diagnosis: Doctor’s Name:

Secondary Diagnosis: Other Diagnosis:

Insurance Carrier: Policy Number:

Policy Holder’s Name: Policy Holder’s DOB:

Relationship to Patient: Patient’s Member ID Number:

Parent/Caregiver Name: Cell Phone:

Email Address: Work Phone:

MEDICAL & OTHER SERVICES

MEDICAL HISTORY

CURRENT MEDICATIONS

CURRENT VITAMINS

ALLERGIES

MEDICAL ALERTS

PREVIOUS TREATMENTS

PREVIOUS MEDICATIONS

HOSPITALIZATION HISTORY

ABA HISTORY LEAVE BLANK

BCBA to complete PIVIT-P

POTENTIAL TRAUMA HISTORY

KNOWN TRAUMA HISTORY

OTHER SERVICES

TYPE OF SERVICES FREQUENCY PROVIDER’S NAME ABLE TO SIGN RELEASE

FORM TO CONTACT?

SPEECH

OCCUPATIONAL
THERAPY

PHYSICAL THERAPY

MENTAL HEALTH
THERAPY
 SCHOOL TEAM IEP
SERVICES

OTHER

AVAILABILITY
PATIENT AVAILABILITY

Monday Tuesday Wednesday Thursday Friday Saturday

9a-5p

PARENT EDUCATION AVAILABILITY

9a-6p

Parent Education Preference:

In Clinic
Via Zoom
Via Phone
Via Email
In Home
If possible, I would like to receive Parent Education while on the waitlist via Telehealth

STRENGTHS & PREFERENCES

Describe your child’s strengths (Example: loving, friendly, good at drawing, is a good big brother, loves to play outside,
etc.):

Describe your child’s preferences (Example: playing alone, quiet spaces, dark rooms, loud music, special toys,
etc.):

BARRIERS TO LEARNING
In general, what do you perceive are your child’s biggest barriers to learning?:

Does your child communicate that anything in particular is challenging or frustrating to them? If yes, what?

OFFICE USE ONLY

Check once BHI has been completed by BCBA Date: _________________
ADVERSE CHILDHOOD EXPERIENCES (ACE) SCORE
Reference: Vancouver EMDR Therapy, PLLC
The ACE (Adverse Childhood Experiences) study is one of the largest scientific research studies of its kind, with over
17,000 mostly middle income Americans participating. The focus was to analyze the relationship between childhood
trauma and the risk for physical and mental illness in adulthood. Over the course of a decade, the results
demonstrated a strong relationship between the level of traumatic stress in childhood and poor physical, mental and
behavioral outcomes later in life.

There are 10 types of childhood traumas measured in the ACE Study.

● Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect.
● Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic
violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a
parent through divorce, death or abandonment.
● Each type of trauma counts as one. So a person who’s been physically abused, with one alcoholic parent, and
a mother who was beaten up has an ACE score of three.
● To find out your ACE score take the ACE Questionnaire here or below.

There are 10 childhood traumas measured in the ACE score. For each question that you answered yes to below you
will receive a point. The higher your ACE score the higher your risk of health, social, and emotional issues. Adults with
a score of 4 or more points are at serious risk.

Please fill this out about yourself, as the parent, or check the following box:
I do not wish to share this information
PARENT ACE SCORE
Prior to your 18th birthday:
● Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or
humiliate you? or Act in a way that made you afraid that you might be physically hurt?
No___If Yes, enter 1 __
● Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you?
or Ever hit you so hard that you had marks or were injured?
No___If Yes, enter 1 __
● Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body
in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
No___If Yes, enter 1 __
● Did you often or very often feel that … No one in your family loved you or thought you were important or
special? or Your family didn’t look out for each other, feel close to each other, or support each other?
No___If Yes, enter 1 __
● Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no
one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you
needed it?
No___If Yes, enter 1 __
● Were your parents ever separated or divorced?
No___If Yes, enter 1 __
● Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very
often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes
or threatened with a gun or knife?
No___If Yes, enter 1 __
● Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
No___If Yes, enter 1 __
● Was a household member depressed or mentally ill, or did a household member attempt suicide?
No___If Yes, enter 1 __
● Did a household member go to prison?
No___If Yes, enter 1 __
Now add up your “Yes” answers: _________ This is your ACE Score.
YOUR CHILD’s ACE SCORE
Please fill this out about your child, or check the following box:
I do not wish to share this information
Prior to your child’s 18th birthday:
● Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or
humiliate you? or Act in a way that made you afraid that you might be physically hurt?
No___If Yes, enter 1 __
● Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you?
or Ever hit you so hard that you had marks or were injured?
No___If Yes, enter 1 __
● Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body
in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
No___If Yes, enter 1 __
● Did you often or very often feel that … No one in your family loved you or thought you were important or
special? or Your family didn’t look out for each other, feel close to each other, or support each other?
No___If Yes, enter 1 __
● Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no
one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you
needed it?
No___If Yes, enter 1 __
● Were your parents ever separated or divorced?
No___If Yes, enter 1 __
● Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very
often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes
or threatened with a gun or knife?
No___If Yes, enter 1 __
● Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
No___If Yes, enter 1 __
● Was a household member depressed or mentally ill, or did a household member attempt suicide?
No___If Yes, enter 1 __
● Did a household member go to prison?
No___If Yes, enter 1 __
Now add up your “Yes” answers: _________ This is your ACE Score.

COMMENTS YOU WANT TO SHARE WITH THE CLINICIAN:

BEHAVIORS OF CONCERN
Open Ended Functional Assessment Interview
Developed by Gregory P. Hanley, Ph.D., BCBA-D
(Developed August 2002; Revised: August 2009)

Language Abilities:
Can understand what is being said to them
Cannot understand very well what is being said to them
Can communicate using Spoken Verbal Language
Cannot communicate using Spoken Verbal Language
Communicates in a different way (please explain):

What are his/her play skills like?

Prefers to play alone
Prefers to play with others
Plays with toys in an odd way
Does not play with age appropriate toys
Plays with age appropriate toys
Plays in a different way (please explain):

What other things do they prefer?

What are the behaviors of concern? What do they look like?

Tantrum (appears to be “on purpose”)
Meltdown (not on purpose, out of their control)
Aggression
Self-Injury
Pica
Saying “No”
Elopement (running away)
Self-Stimulatory (we will not target this for reduction)
Property Destruction
Spitting
Screaming
Flopping
Ignoring
Other (please explain):

What are the top 3 most concerning behaviors?

What is the single-most concerning behavior?

Has your child, or anyone ever gotten hurt due to the behavior(s) of concern?
Yes
No

How intense can the behaviors of concern get?

Mild
Moderate
Severe

Are there precursor behaviors (signs) that seem to indicate that severe behaviors of concern are about to
occur (Example: child begins to whine before they hit you)?

Under what conditions or situations are the behaviors of concern most likely to occur (Example,
hungry/tired/not getting their way/told to clean up)?

Do the behaviors of concern reliably occur during any particular activities (Example: always during
meal time, always in the car, etc)?

What seems to trigger the behaviors of concern?

Do behaviors of concern occur when you break routines or interrupt activities? If so, describe.

Do behaviors of concern occur when it appears that they won’t get their way? If so, describe the things
that they often attempt to control.

How do you and others react or respond to the behaviors of concern?

What do you and others do to calm them down once they engage in the behaviors of concern?

What do you and others do to distract them from engaging in the behaviors of concern?
What do you think they are trying to communicate with their behavior(s) of concern, if anything?

Do you think this behavior of concern is a form of self stimulation? If so, what gives you that
impression?

Why do you think they are engaging in the behaviors of concern?

PRESENT PERCEIVED DIFFICULTIES WITH SCHOOL LEARNING

DIFFICULTY WITH (Check all that apply):
Paying Attention
Waiting
Imitating
Labeling
Sitting in seat
Following Directions
Other:

OTHER BARRIERS (Check all that apply):

Prompt Dependent
Minimal Independent Skills
Unable to Match
Unable to Count
Not Toilet Trained
Cannot Self-Feed
Sensory Defensiveness
Weak Motivators
Other:

CURRENT SKILL LEVELS

Mostly Needs Occasional Needs Full Support Unsure
Independent Support

Toilet Trained

Self-Care

Safety

Pre-Academic

Social
 Communication

FAMILY INFORMATION
Who makes up your current household?

Do you have any pets? If so, how does your child respond to the pets?

How many siblings are in the home, and their respective ages:

How does your child interact with siblings?

Who do you think will be the family member(s) involved in minimally weekly?

What is the Primary Language spoken at home?

Are there any other languages spoken?

Is there any cultural information that you wish to share?

Are there any preferred pronouns that you wish to share for them or for family members?

SCHOOL INFORMATION

Is your child enrolled in school? (if yes, where?): If NO, skip to the last question*

What grade is your child in?:

What was the date of the last IEP meeting? Please request a copy if you do not have one.

Does your child require support in the school environment?

If your child is under the age of 6, Do you have plans to enroll your child in school?
COMMUNITY INFORMATION

Does your child participate in any clubs, social groups, activities outside of school? If not, do they want
to?

How is being in the community with your child? Are there any difficulties?

ASSENT WITHDRAWAL
We do not wish to teach people compliance. When we observe someone who is engaging in escape avoidance
behavior from a task, we are curious about the situation. When someone tells us (in whatever way the wish to
communicate), we honor this unless there is a risk of imminent harm. We honor the assent withdrawal and analyze
what environmental manipulation needs to be made. What are some ways that your child might tell us that they are
unhappy, or do not want to do the things we are asking them to do?

Physical (e.g., flopping or running away):

Verbal (e.g., yelling no, crying):

Other (e.g., zoning out):

Is there anything else that you would like to share that was not covered in this intake questionnaire?

IN OFFICE USE ONLY

PIVIT-P Completed
BHI Completed
PFA Completed
Appropriate Assessment Selected