case manager intake Psycho-Social Intake V2 "*" indicates required fields Case Manager*Please SelectKelley GreenwoodRebecca McCauleyToday's Date MM slash DD slash YYYY Docusign Information ConfirmedPlease SelectYesNoParent or Guardian Name* First Last Parent or Guardian Email PhoneChilds name Child's Age Has your child ever been assessed/evaluated by an Occupational Therapist, Speech and Language Therapist, Psychiatrist, Psychologist, Special Educator, or other mental health counselor?*Please SelectYesNoAssessed/Evaluated DetailsAre you currently working with another ABA provider?Please SelectYesNoWhich ABA provider? Please provide the name of the physician that diagnosed your child with autism First Last Type of Specialist Date of evaluation MM slash DD slash YYYY Diagnosing Physicians Phone NumberDid your child receive early intervention?*Please SelectYesNoDoes your child currently attend school or daycare?Please SelectYesNoWhat is the name of their school or daycare? Current School District Grade Does CPT have permission to contact the school for coordination of care?*Please SelectYesNoIf yes, be sure to include the contact info with the Docusign consent form.Is your child receiving or has your child received special services or accommodations at school?*Please SelectYesNoDetails of Special School Services or AccommodationsWhich developmental milestones were delayed? Sitting up Babbling/talking Standing on own Responding to sound Reaching for items/parents Recognizing sound of own name Walking Eye Contact Select AllMedicalDoes the child have any allergies, medical conditions or taking any medications?*Please SelectYesNoSpecify allergies, medical conditions or medicationsHomeParents: Married, Single, Separated, DivorcedPlease SelectMarriedSingleSeparatedDivorcedAre both parents aware ABA is being requested?Please SelectYesNoNames, ages, and relation to child of all other individuals in the homePrimary Language Please describe below important cultural practices, rituals, traditions, or beliefs that you believe are important for us to be aware of prior to initiating a therapeutic relationshipLikes/DislikesPreferences (favorite activities, food, interests/topics, sensory)Dislikes (aversions)Parental ConcernsParental GoalsWhat would you like us to help your child with? Behavior Play/Leisure Toilet training Social Skills Language/communication Feeding issues Is there anything else that you would like us to know?Does the parent understand the importance of maximizing hours?Please SelectYesNoWas the parent informed of our Social Skills Groups?Please SelectYesNoWhich programs are the parents interested in? When are they interested in receiving services? (Hours, Days) CommentsThis field is for validation purposes and should be left unchanged.
