CLIENT INTAKE & ASSESSMENT FORM

Primary Caregiver

Emergency Contact

How often does your child use the following methods to communicate

For each of the areas below, indicate whether you would consider it an area of strength for your child or an area of growth (potential goal)

I. SLEEPING

With regard to the child's sleep routine how often does the child...

II. EATING

II. TOILETING

How often does your child engage in any of the following challenging behaviors?

By checking the boxes below and signing this form, I acknowledge and agree to the following: