Description
Stop sending families a basic intake form and hoping for the best. This complete 9-form intake package gives you everything you need to conduct a thorough, clinically informed, legally sound intake before your first BCBA session — all in one professional, editable package.
Forms included:
Form 1 — Comprehensive ABA Intake Questionnaire 10 sections covering: client and guardian information, referral history, medical and developmental history, behavioral concerns with frequency/intensity/antecedent/consequence questions, communication profile, social skills, adaptive behavior rating table, academic and school information, and family/cultural context.
Form 2 — HIPAA Notice of Privacy Practices & Acknowledgment Includes client rights, permitted uses and disclosures, and signature block.
Form 3 — Informed Consent for ABA Services Benefits, risks, alternatives, client rights, and consent statement.
Form 4 — Photo, Video & Audio Recording Consent Three separate authorizations: clinical use, training/education use, and photographs.
Form 5 — Release of Information Authorization Standard ROI with purpose, expiration, and revocation language.
Form 6 — Communication Preferences Form Contact method, language, accessibility needs, and progress reporting preferences.
Form 7 — Reinforcer Preference Survey Five categories (food, toys, technology, physical/sensory, social) with 5-point rating tables. Re-administer every 30–60 days.
Form 8 — Caregiver Stress & Wellbeing Screener 12-item rating scale covering exhaustion, isolation, anxiety, and support — with caregiver resource list. Re-administer quarterly.
Form 9 — Goals Prioritization & Typical Day Narrative 20-goal ranking table plus six time-slot narrative sections (morning through bedtime and weekends).
All forms are fully editable — customize with your agency name, logo, and branding. Note: Forms 2–5 contain legal language. Review with your agency's legal counsel and adapt to your state's specific requirements before use.
Created by Onix Dobarganes, LMHC, BCBA | Spectrum Behavior Consultants LLC
Highlights
Description
Stop sending families a basic intake form and hoping for the best. This complete 9-form intake package gives you everything you need to conduct a thorough, clinically informed, legally sound intake before your first BCBA session — all in one professional, editable package.
Forms included:
Form 1 — Comprehensive ABA Intake Questionnaire 10 sections covering: client and guardian information, referral history, medical and developmental history, behavioral concerns with frequency/intensity/antecedent/consequence questions, communication profile, social skills, adaptive behavior rating table, academic and school information, and family/cultural context.
Form 2 — HIPAA Notice of Privacy Practices & Acknowledgment Includes client rights, permitted uses and disclosures, and signature block.
Form 3 — Informed Consent for ABA Services Benefits, risks, alternatives, client rights, and consent statement.
Form 4 — Photo, Video & Audio Recording Consent Three separate authorizations: clinical use, training/education use, and photographs.
Form 5 — Release of Information Authorization Standard ROI with purpose, expiration, and revocation language.
Form 6 — Communication Preferences Form Contact method, language, accessibility needs, and progress reporting preferences.
Form 7 — Reinforcer Preference Survey Five categories (food, toys, technology, physical/sensory, social) with 5-point rating tables. Re-administer every 30–60 days.
Form 8 — Caregiver Stress & Wellbeing Screener 12-item rating scale covering exhaustion, isolation, anxiety, and support — with caregiver resource list. Re-administer quarterly.
Form 9 — Goals Prioritization & Typical Day Narrative 20-goal ranking table plus six time-slot narrative sections (morning through bedtime and weekends).
All forms are fully editable — customize with your agency name, logo, and branding. Note: Forms 2–5 contain legal language. Review with your agency's legal counsel and adapt to your state's specific requirements before use.
Created by Onix Dobarganes, LMHC, BCBA | Spectrum Behavior Consultants LLC
