ABA Intake Form

The ABA Intake Form gathers comprehensive background information from caregivers to guide assessment, treatment planning, and service recommendations. It includes:

Key Areas Covered:

• Demographic and contact information
• Diagnosis, medications, allergies, and medical history
• Prior assessments (Vineland, BASC, others)
• Communication level and social skills
• Behavior concerns at home and school
• School placement, IEP/504 status, and teacher reports
• ABA referral history and reasons for seeking services
• Parent-identified goals and priorities
• Family structure and home environment
• Daily living skills (sleep, eating, toileting)
• Current therapies (Speech, OT, PT, feeding)
• Potential reinforcers and preferences

Behavior Review Checklist

The Behavior Review Checklist is a structured screening tool used to identify specific behavioral and safety concerns. Caregivers select applicable behaviors across multiple categories.

Key Areas Covered:

• Safety risks (elopement, self-harm, climbing, etc.)
• Feeding and oral behaviors (pica, food refusal, excessive eating)
• Self-injurious behaviors (head hitting, skin picking, eye poking)
• Hygiene and self-care refusals (teeth brushing, bathing)
• Aggression and disruptive behaviors (tantrums, property destruction)
• Vocal and communication concerns (echolalia, verbal threats)
• Social and behavioral challenges (stealing, inappropriate behaviors)
• Sensory-related behaviors (covering ears, mouthing objects)