BEHAVIORAL INFORMATION FORM

Personal Background Information

Child’s full name (please include first, middle, and last names): _______________________________

Date of birth: ________________________ Child’s age at time of application: ___ years

Mother’s name: _______________________ Father’s name: ________________________________

Address of residency: _________________________________________ Postal code: _____________

Contact numbers: Home phone: ________________________

Cell phone: 1) _________________________ Relation ______________________
Cell phone: 2) ________________________ Relation ______________________

Medical Information

Primary Diagnosis ________________________________

Secondary Diagnosis (If any): ______________________________

Other medical issues/concerns (If any): __________________________

Child’s age at diagnosis ____________

Location of where the diagnosis was made (clinic, hospital) _______________________________

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Name of practitioner who diagnosed your child _______________________________

Is your child on any medications? Yes __ No __ If yes, please indicate name of

medication(s) and for what medical reason it was prescribed ____________________________________

______________________________________________________________________________________

______________________________________________________________________________________

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 Other Services Involved

Please indicate any other services involved in your child’s intervention:

Speech and language therapy

Name: _____________________ Center/Clinic: ___________________________

Number of therapy hours your child is receiving ____________________________

Impression of the therapy your child is receiving ____________________________

Evaluation report: Yes___________ No____________

Occupational therapist (OT)

Name: _____________________ Center/Clinic: ____________________________

Number of therapy hours your child is receiving ____________________________

Impression of the therapy your child is receiving ____________________________

Evaluation report: Yes___________ No____________

Current Behavioral Therapist

Name: _____________________Center/Clinic: ____________________________

Number of therapy hours your child is receiving ____________________________

Evaluation report: Yes___________ No____________

Impression of the therapy your child is receiving ____________________________

Preschool/Daycare/School Name: ______________________________________

Any special needs support in place? Yes ___ No ___

Describe ___________________________ (e.g., SEA, aide, ABA support worker)

Impression of the therapy your child is receiving ____________________________

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 Behavior Concerns

Difficulty Difficulty chewing Impulsiveness Toe-walks Distractibility

swallowing food

Mouthing objects Place’s self in Difficulty with Echolalia Poor eye-hand

inappropriately dangerous situations change coordination

Excessive drooling Inappropriate toy Dislikes being hyperactivity Hand flapping

play touched

Biting, pinching, Does not understand Poor/inappropriate Clumsy, trips Delay in pulling
etc. simple directions eye contact often up, crawling

Uses only 1-2 Difficulty sleeping Bedwetting Seizure activity Spins

words inappropriately

Refusal to obey Runs from parents, Poor social Poor handwriting Lines up objects
teachers, etc. interaction

Fixates on specific Food Poor sentence Delay in sitting Poor balance

item/activity allergy/Sensitivity structure up

Stuttering No verbal language Difficulty Weakness in Unable to ride

answering arms, legs, trunk bicycle
questions

Unable to catch Increased muscle Weak hand Unable to Unable to skip or

tossed ball tone in arms, legs muscles dress/undress hop on one foot
self

Cannot feed self Intolerant to textures Hums to self Stimming Sensory issues
independently activity / hand
flapping

If others, Specify:
_______________________________________________________________________________________
_______________________________________________________________________________________
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 Parents’ Goals

Please list the goals you want your child to achieve: (e.g., to communicate with peers

and adults)

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

4. ___________________________________________

5. ___________________________________________

Printed name of person completing form:

MARIYA UBAID KHAN

BEHAVIORAL THERAPIST (BACB, USA)

CLINICAL PSYCHOLOGIST

Signature of person completing form: _________________________________________

Date Completed: ____________________