GOAL GETTERS THERAPY CENTER

#103, 1 Road, Quezon Hill, Baguio City. 2600

09209141566 / 09774726741
[Link] and goalgetterstc@[Link]

Client Intake Forms

Client Name: _________________________________________ Gender: M F

Address: _____________________________________________ Date of Birth: _________________

Parent/Guardian Information:

Mother’s Name: _____________________________ Father’s Name: _____________________________

Address: ____________________________________ Address: ____________________________________

Phone Number: _____________________ Phone Number: _____________________

Viber Number: _____________________ Viber Number: _____________________

Email: _____________________________ Email: _____________________________

Siblings/Household Members (Other than parent/guardian)

Name: ______________________________________ Name: ______________________________________

Date of Birth: ________________________________ Date of Birth: ________________________________

Relationship: _________________________________ Relationship: _________________________________

Name: ______________________________________ Name: ______________________________________

Date of Birth: ________________________________ Date of Birth: ________________________________

Relationship: _________________________________ Relationship: _________________________________

Other Services Provided (Speech/PT/OT, etc.):

Name of Provider: _______________________________ Name of Provider: _______________________________

Services Provided/Times per week: ________________ Services Provided/Times per week: ________________

Child’s Educational Background

Name of school: __________________________________ Name of school: __________________________________

Level: ____________________________________________ Level: ____________________________________________

Primary Diagnosis : __________________________________ Diagnosis Date(s): __________________________

_____________________________________________________ Diagnosing Professional: ____________________

Secondary Diagnosis : __________________________________ Diagnosis Date(s): __________________________

_____________________________________________________ Diagnosing Professional: ____________________

Medical Conditions (if any): __________________________________________________________________________________

Allergies: ___________________________________________________________________________________________________

Diagnosing Professional: ____________________________________________

Special Diet Information: ___________________________________________________

Current Medications

Medication Dosage Frequency

ABA Services Requested:

___ Home Based ___ Clinic Based ___ School Based ___Social Skills Group

Available Service Times:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

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

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Problem Behavior Information:
Behavior (Please describe) Frequency Duration Severity
(hourly, daily, (how long does the Mild – Disruptive but little risk
weekly, less often, behavior occur) Moderate- property damage or
more often, etc.) minor injury
Severe- Significant threat to
health or safety

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

present)

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

present)

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What typically happens right BEFORE problem behavior occurs?

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What typically happens right AFTER problem behavior occurs?

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How do you address the behavior?

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What motivates/interests your child?

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Please list any other important information you would like us to know about your child.

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Behavioral Language Assessment

Expressive Verbal Skills

Describe your child’s ability to babble speech sounds:

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Describe your child’s spontaneous language:

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Describe how your child indicates what he/she wants:

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Describe the type and number of items that your child asks for:

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Describe your child’s ability to imitate vocal sounds, words, phrases:

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Describe your child’s ability to label items, events, or actions (spontaneous? how many? how

often?):

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Describe your child’s ability to answer questions:

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Receptive Language/Listener Responding Skills (following directions):

Describe your child’s ability to follow directions and routines within context or with model:

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Describe your child’s ability to follow directions and routines out of context or without a model:

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Motor Imitation

Is your child able to imitate simple motor movements such as clapping, waving? Y N

Is your child able to imitate actions using objects---using “do this” with a model? Y N

Describe your child’s interest in doing what others are doing: __________________________________________________

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Describe your child’s ability to participate in turn-taking activities: ______________________________________________

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Play Skills

Describe your child’s play with toys (identify the toys and length of time involved):

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Does your child use the toys as intended or as self-stimulatory objects?

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Describe your child’s interactive play with other children:

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Describe your child’s imaginative and pretend play skills:

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Self-help Skills

Describe how your child feeds him/herself:

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Is your child toilet trained completely? Y N

If not, what program did you use or have your tried with your child?

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Does your child dress independently: Y N Describe: ______________________________________________

Describe any household tasks that your child assists with:

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Describe how your child responds to situations of danger:

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Parents Guardian Signature Date