New Client Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Child's Name * Date of Birth * Parent(s)/Guardian(s) Name(s) * Address * Mailing Address (if different) Phone * Email * Child's School Child's Teacher Teacher's Email Teacher's Phone Brief Background Strengths / Likes / Dislikes List the top 5 behavioral concerns (home/school) 1. 2. 3. 4. 5. What interventions (if any) have been tried up to this point? Home: School: What is your child's medical history? Formal diagnosis and date of diagnosis: Special diets Medications How are things at school? (Describe Concerns) Aggression: Behaviors: Current Interventions (even if they are not successful) Does he/she get suspended? If yes, how often? Do you recognize environmental triggers? (Lights, noise, people, smells...) Siblings (names and ages) Any other concerns or things I should know?