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Childgardens
ABOUT US
OUR FOCUS
HOW DO WE HELP?
EARLY PROGRAM
CONTACT
CAREERS
Childgardens
ABOUT US
OUR FOCUS
HOW DO WE HELP?
EARLY PROGRAM
CONTACT
CAREERS
PARENT INTERVIEW
TODAY´S DATE
CLIENT´S NAME
DOB
Street Address
City
State/Province
ZIP / Postal Code
PARENT/GUARDIAN
Street Address (If Different)
City (If Different)
State/Province (If Different)
ZIP / Postal Code (If Different)
Phone
1) HOW DID YOU FIND US?
Internet
Social Media
Doctor Referral
Others
SPECIFY OTHERS:
2) WHO GAVE THE REFERRAL?
Pediatrician
Neurologist
ABA Referral
Other Referrals
WHAT WAS THE DIAGNOSIS?
3) SOCIAL RELATIONSHIPS (Mark all that apply)
Mom
Dad
Siblings
Grand parents
Friends
Others
SPECIFY OTHERS:
WHO DOES THE LIVES WITH:
Mom
Dad
Siblings
Grand parents
Friends
Others
SPECIFY OTHERS:
4) MEDICATIONS
0 / 1000
5) SCHOOL
Yes
No
If Yes, School Name:
GRADE
1st
2nd
3rd
4th
5th
6th
7th
8th
Other
SPECIFY OTHER:
COMPLAINTS FROM THE TEACHER (If Any):
6) ABA THERAPY PREVIOUSLY
Yes
No
AT WHAT AGE:
7) BEHAVIORS
AGRESSION
YES
NO
iF YES, FREQUENCY AT WEEK:
AVOIDANCE: (Avoids something he/she shouldn´t)
YES
NO
iF YES, FREQUENCY AT WEEK:
BOLTING: (Run or Walk Away Within a Safe Area)
YES
NO
iF YES, FREQUENCY AT WEEK:
CLIMBING:
YES
NO
iF YES, FREQUENCY AT WEEK:
DEFIANT BEHAVIOR: Refuses to obey rules, continually challenges authority
YES
NO
iF YES, FREQUENCY AT WEEK:
DIFFICULTY COMMUNICATING WANTS/NEEDS
YES
NO
iF YES, FREQUENCY AT WEEK:
DIFFICULTY INITIATING AND SUSTAINING SOCIAL INTERACTIONS
YES
NO
iF YES, FREQUENCY AT WEEK:
ECHOLALIA(Word repeated that is not used for information)
YES
NO
iF YES, FREQUENCY AT WEEK:
ELOPEMENT(Run or Walk Away to An Unsafe Place)
YES
NO
iF YES, FREQUENCY AT WEEK:
EXCESSIVE DRINK(Polydipsia)
YES
NO
iF YES, FREQUENCY AT WEEK:
EXCESSIVE EATING
YES
NO
iF YES, FREQUENCY AT WEEK:
EYE POKING
YES
NO
iF YES, FREQUENCY AT WEEK:
FOOD REFUSAL
YES
NO
iF YES, FREQUENCY AT WEEK:
HEAD BANGING
YES
NO
iF YES, FREQUENCY AT WEEK:
HYPERACTIVE
YES
NO
iF YES, FREQUENCY AT WEEK:
INAPPROPIATE SEXUAL BEHAVIOR TOWARD SELF
YES
NO
iF YES, FREQUENCY AT WEEK:
INAPPROPIATE SEXUAL BEHAVIOR TOWARD OTHER
YES
NO
iF YES, FREQUENCY AT WEEK:
INATTENTION
YES
NO
iF YES, FREQUENCY AT WEEK:
INDUCE VOMITING
YES
NO
iF YES, FREQUENCY AT WEEK:
Field Group
LYING
YES
NO
iF YES, FREQUENCY AT WEEK:
ISOLATION
YES
NO
iF YES, FREQUENCY AT WEEK:
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