Client Intake Form

All information given is strictly confidential. At no given point is information disclosed or shared without client’s written consent. You may skip any questions you do not feel comfortable answering. 

DEMOGRAPHIC INFORMATION

Gender

EDUCATIONAL HISTORY 

Does your child have an IEP?

HOUSEHOLD INFORMATION

MEDICAL INFORMATION

Is your child taking any daily medication(s) or supplements?

BEHAVIOR SPECIFICS

Are there times of the day whe the behavior is more likely to occur?
Are there specific activities when the behavior is more likely to occur?
How frequently is the behavior occuring?
Are there circumstances that occur on some days and not others that make behavior more likely to occur?

Please rate how likely you are to use each of the strategies listed.

Let situation go
Take away a privilege
Asking a additional chore
Take away a tangible/object
Send to room
Reason with child
Send to time out

Thanks for submitting!

Please download here our Service Agreement form. Once you have completed the document, please scan and email it to dynamicbehaviorsolutions@gmail.com