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SNDS Initial Intake Form

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Inaam Ahmad
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19 views

SNDS Initial Intake Form

Uploaded by

Inaam Ahmad
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Initial Intake Interview Form

Contact Details

Name of the client: Shaza Khattab


Age: 16 Date of birth: March 10, 2007 Gender M/F: F
Languages known: Arabic/English/Aramic Language spoken at home:
Arabic/English/Aramic
Mother’s name: Safa Issa
Phone number: (647)648-8416
Email address: [email protected]
Home address: 225 Markham Rd, Apt 110

Father’s name: Ahmad Khatab Phone number: (437)988-6044


Email address: [email protected]

Home address: (If different from above address): Same as the mother

Other siblings, their names and age:

Inaam Khattab age 18, Fatima Khattab age 12, Jana Khatab age 7, Mohammad Khatab age 3.

Relationship with client: Father


Legal Guardian name: Ahmad Khatab
Phone number: (437) 988-6044
Caregiver in emergency(Name): Ahmad Khatab
Phone Number; (437) 988-6044
Home address: 225 Markham Rd, Apt 110

ABA Services Requested: Home Based School based Center based Social Skills Group
Mode of service: Yes In person Virtual (Online)
Available Service Times:
Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm

Additional Comments

What are your goals and/or expectations for the services requested?

Problem Behavior Information:


Behavior (Please describe in detail)

Frequency (hourly, daily, weekly, less often, more often, etc.)

Duration (how long does the behavior occur)


Severity level of behaviors
Mild –Tantrums, pushing, crying, throwing objects
Moderate- Disruptive but little risks
Severe- Property destruction, Self- injurious behaviors, picking skin
Profound- Significant threat to health or safety

What situations are these behaviors MOST likely to occur? (Days/times/settings/activities/persons


present)

What situations are these behaviors LEAST likely to occur? (Days/times/settings/activities/persons


present)

What typically happens right BEFORE problem behavior occurs?

What typically happens right AFTER problem behavior occurs?

How does the client communicate (PECS, device, words, signs, grabs, sentences).

Developmental concerns
☐ Social

☐ Peer Interaction

☐ Play/Leisure

☐ Self-Help (Dressing/Toileting/Feeding/Etc.)

☐ Dietary/ Allergies
☐ Other

☐ Academics (Reading/Writing/Math)

☐ Executive Functioning (Organization/Flexibility/Attention)

Previous Evaluations/Assessments

Please list any school testing and/ or other evaluations of the client’s skills. 1. Has the client ever been
assessed/evaluated by an Occupational Therapist, Speech and Language Therapist, Psychiatrist,
Psychologist, Special Educator, or other mental health counselor?

No Yes Unknown

If yes, please provide the following information:

A Name: Type of Specialist Date

of evaluation:

Purpose of Evaluation / Services:

Results of Evaluation:

B. Name: Type of Specialist Date of evaluation:

Purpose of Evaluation / Services:

Results of Evaluation:

C. Name: Type of Specialist

Date of evaluation:

Purpose of Evaluation / Services:

Results of Evaluation:
Educational History

Please list the schools attended from most recent.

1. Is the client currently enrolled in school or day care?

No Yes N/A

School Name/ Day care name

School District

Program or Grade level:

2. Please list any other schools that the client has attended:

A. School Name:

School District:

Years of attendance: Grade Levels:

B. School Name:

School District:

Years of attendance: Grade Levels:

3. Is the client receiving or has the client received special services or accommodation at school?

No Yes

If yes, please explain what type: (e.g. IEP, ) and what is the focus of needs for the child?

Client’s Interests Please indicate anything that the clinicians should know when working with
him/her.

1. Preferences (favorite activities, food, interests/topics, sensory):


2. Dislikes (aversions):

3. Other:

Concerns

1. Reason for seeking ABA, IBI, Social skills or life skills services [Please explain]:

2. Please list client strengths:

Cultural Considerations

Please describe below important cultural practices, rituals, traditions or beliefs that you believe are
important for us to be aware of prior to initiating a therapeutic relationship.
Information on funding:

Do you receive funding:

Are you at waiting list:

Private payment:

Any other information:

Please attach a copy of your child’s reports (please include all that apply):

☐ Diagnostic Evaluation Report

☐ IEP/ any school accommodation document

☐ Functional Behavior Assessment (FBA) /Behavior Service Plan (BSP)/ Discharge report (if taken
ABA, IBI services earlier)

☐ Prescription of physician if any medical conditions are present (epilepsy or seizures, ADHD,
Down syndrome, allergies, etc

☐ Other:

SIGNATURE and ACKNOWLEDGEMENT


Parent/Guardian Signature:
Date: I hereby certify that the above statements are true
and correct to the best of my knowledge and understand all information in this packet will become part of
the patient’s clinical file.
Parent/Guardian Name:

Provider’s Signature:
Date:
by signing, I hereby confirm that I have reviewed with the
parent/guardian the information set forth in this document and understand all information in this packet
will become part of the patient’s clinical file.
Provider’s
name: Date:

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