Parent or Guardian 1 *

Primary Phone Number *

Address *

County of Residence *

Marital Status *

• Married
• Divorced
• Co-Parenting
• Living Together
• Single

Parent or Guardian 2

Primary Phone Number

Address: (if different than above)

County of Residence: (if different than above)

With whom does the learner legally reside with ? *

Emergency Contact 1 *

Emergency Contact 1 Phone Number *

Emergency Contact Address

Emergency Contact 2 *

Emergency Contact 2 Phone Number *

Emergency Contact Address

Are there any current legal issues related to the learner we should be aware of (example: DCF involvement)? *

• Yes
• No

If yes, please list and explain

Are there any spiritual, vocational, cultural, educational or other circumstances that would affect treatment for your learner? *

• Yes
• No

If yes, please list and explain

Are any family members known to have the following medical conditions ? *

For any ‘Yes’, please specify details *

Please list the names and ages of any other individuals that live in the home *

Does your learner have any allergies to food, medication, or other substances?: *

• Yes
• No

List any allergies and adverse reactions that occur, or list NKA if no known allergies.: *

Please tell us why you are seeking treatment for your learner: *

Is your learner currently taking any medication ? *

• Yes
• No

Please list any prescription medications your learner is currently taking.

Additional Medications

Does your learner have a history of any of the following? *

Please share details of any relevant medical tests or evaluations completed

Does your child currently attend school ? *

• Yes
• No

Does your child currently have an IEP ? *

• Yes
• No

School Name

What is your learner's current grade in school?

Please describe any special learning accommodations your child receives in school ?

What days and times does your child attend school ?

Please describe the teaching goals & objective for your child's current school year or please provide a copy of the current IEP.

Upload IEP if available.

How does your child feel about their current educational program ?

How do you feel about your child’s current educational program ?

Has your child ever been suspended or expelled from school or transportation services ?

Please share copies of any treatment plans, assessments, or progress notes available from the past 12 months.

Has your learner received any rehabilitative therapies, now or in the past ?

Please describe your learner's response to treatment and any notable progress or challenges

Is your learner currently receiving ABA therapy or has your child received ABA therapy in the past ? *

• Yes
• No

If so, please state the start date, supervising clinician, company name, phone number or email address

If so, please describe the past or current program goals and objectives and how specific goals are taught

Please list any other community resources that support your family and/or your learner

List any relevant organizations, contacts, or activities.

Please provide the following information regarding your learner’s developmental milestones. If not yet achieved, list N/A. *

Are there any other concerns you have that you have not mentioned above? *

Please describe any unusual circumstances that took place during your learner’s pregnancy and delivery. *

Please describe any notable experiences your learner had with meeting developmental milestones. *

Please describe any notable challenges your learner experienced with toilet training. Provide details about the age at which your learner successfully completed daytime and nighttime toilet training. *

Please detail the age at which your learner began childcare and any notable circumstances. *

Please detail the age at which your learner began schooling and any notable circumstances. *

Please detail your initial concerns regarding your learner’s development, and the age at which that occurred. *

Please detail your learner’s current communication skills and any concerns that you have. *

In 1-2 sentences, how would you describe your child (strengths, personality, interests, etc.)? *

On a scale of 0 to 5, please rate the following as it pertains to your learner: *

Who shares the responsibility of disciplining your learner at home?

Please indicate which disciplinary techniques are used at home:

Other:

Functional Assessment Interview of Possible Functions of Problem Behavior

Does your learner engage in any self-injurious behaviors? *

• Yes
• No

If yes, please describe what this looks like and your typical response. If no, put N/A. *

Does your learner engage in aggressive behaviors towards others. *

• Yes
• No

If yes, please describe what this looks like and your typical response. If no, put N/A. *

Does your learner elope from buildings and/or outdoor areas ? *

• Yes
• No

If yes, please describe what this looks like and your typical response. If no, put N/A. *

Please describe any other safety concerns that you have for your learner. *

Please list any other problem behaviors your learner exhibits. *

Please explain how these problem behaviors interfere with daily activities *

Thinking of the behaviors you described above, please share any relevant information about why you think they occur.

Do these problem behaviors occur during specific times (time of day, week, month, year, etc.) ?

If you do not have details to share, put "unsure"

Do these problem behaviors occur in specific settings (locations, activities, events, etc.) ?

If you do not have details to share, put "unsure"

Is your learner looking for a specific response to these behaviors (access to something, removal from somewhere, attention from someone, etc.) ?

If you do not have details to share, put "unsure"

How often do the problem behaviors occur?

If you do not have details to share, put "unsure"

What does a ‘crisis’ look like for your learner ? *

How often does a crisis experience occur ?

What typically happens immediately before and immediatelyafter a crisis experience occurs? *

Describe any important events and your child’s response to these events.

What strategies do you use to de-escalate and reduce the occurrence of crisis situations for your learner ?

Describe short-term and long-term strategies.

What results have you noticed in your learner’s response to the strategies you described ? *

Describe your learner’s ideal behaviors that would occur instead of the stated problem behaviors in a crisis situation? *

Please list your learner’s most motivating items, activities, and foods:

Goals and Expectations

For each domain, please describe the current expectations you hold for your learner, and your goals for the next 12 months.

Home Environment *

School/Academic Environment *

Community Environment *

Please describe any other concerns or expectations regarding your learner's current behavior, communication, and social skills *

What are the 3 biggest concerns you have for your learner over the next 12 months? *

What goals and expectations do you have for your learner’s outcomes other the next Ten years? *

Please list all family members and other stakeholders that will be involved in your learner’s treatment (Father, grandmother, babysitter, physical therapist, etc.) *

Please describe any barriers to including the above listed stakeholders in Collaboration of Care Training: *

Please provide me with a copy of my completed responses at the email address listed below

The information that I have provided is true to the best of my knowledge. I understand that this information will be used to inform a Functional Behavior Assessment to be completed by a Licensed Professional for the purposes of determining if my child is eligible for services with Autism Prime Therapies. I authorize Autism Prime Therapies to use any of the information provided for the purposes of coordinating care and to complete a Functional Behavior Assessment for my child.

Signature*

Full Name*

Email *

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