Client Intake Form — Harmony House ABA

Background information

Member name *

Date of birth *

Date of intake

Parent/guardian name *

Email *

Phone *

School placement

IEP in place?

YesNo

Living situation

Family history (developmental / medical)

Medications (one per line)

Previous ABA services

Previous ABA services?

YesNo

Previous provider

Diagnostic documentation (required)

Documentation on file *

Diagnostic evaluation on fileSupport letter on fileNot available (explain below)

If not available, please explain

Current services

Referral source

Family strengths & supports

Strengths and supports (check all that apply)

Strong caregiver involvement in treatmentConsistent routines in the homeEffective communication within familySupportive extended familyAccess to transportationEngagement with school teamAccess to community resources

Other strengths

Narrative (required)

Cultural variables impacting care (language, beliefs, routines) *

Primary language *

Environmental factors impacting services (housing, schedule, stressors)

Community supports & resources

Communication & social skills

Reinforcers & preferences (required)

Signature

Typing your full name below acts as your electronic signature.

Parent/Guardian signatureDate

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