Behavioral Intervention Services, Inc.

Intake Application

To be completed by parent or guardian. Please print.

 
Child’s Full Name: ___________________________ Age: __________ Sex: _________

Birthdate: _______________ Birthplace: ______________________________________

School Presently Attending:__________________________________________________

Present Teacher:_____________________________________________________________

Family History

Parent information:   Father                         Mother 

Full name _________________________________  ________________________________

Age       _________________________________  ________________________________

Address   _________________________________  ________________________________

Phone     _________________________________  ________________________________

Fax       _________________________________  ________________________________

E-Mail    _________________________________  ________________________________

Place of Employment________________________  ________________________________

Marital Status   ___ Married ___ Divorced      ___ Married ___ Divorced 
                 ___ Widowed ___ Remarried     ___ Widowed ___ Remarried 

General Health ___________________________  _________________________________

Brothers and Sisters

Name ___________________________________  ___________________________________

Age  ___________________________________  ___________________________________

Sex  ___________________________________  ___________________________________

School Grade Completed _________________  _________________

Living at Home _________________________  __________________________

Are there any other persons living in the home? _______ (If yes, explain.) 

_____________________________________________________________________________

_____________________________________________________________________________

History of the Child

Age when you first recognized a delay: _________________________________

Specifics that made you think there was a delay: ____________________________

_____________________________________________________________________________
 
Age when child was diagnosed: _______________________________________________

Person and agency who performed the diagnosis
please include the phone number): 

_____________________________________________________________________________

_____________________________________________________________________________

Tests used during diagnosis and the results: 

	Test Name                                    Results 
_________________________________    ________________________________________ 

_________________________________    ________________________________________ 

_________________________________    ________________________________________ 

_________________________________    ________________________________________ 

Any other comments about the testing/diagnosis
(i.e., mood of child, environment, etc.). 

_____________________________________________________________________________ 

Name of child’s physician: __________________________________________________

Date of last physical examination: __________________________________________

Any vision or hearing problems. _____ If yes, explain?_______________________

List any medications your child takes: ______________________________________

List any allergies your child has: __________________________________________

_____________________________________________________________________________
 
Does the child have any speech problems: ____ If yes, is he/she having 
speech therapy OR has he/she ever had speech therapy and how often? _________
   
_____________________________________________________________________________ 

Is your child potty trained for urination? _____ Bowel movements? ___________
 
From what you can tell, is your child right or left handed? _________________ 

Social History of the Child

Does your child display any aggressive or self-injurious behaviors? _________

If yes, explain: ____________________________________________________________

Does your child display any self-stimulatory behaviors? _____________________

If yes, explain:_____________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________


Please list any activities that your child really enjoys and any that you 
know of that are particularly reinforcing to him/her that you wouldn’t mind 
being used in therapy sessions:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Is there any other additional information about your child that you feel is 
necessary to be aware of before beginning this home program? _____ If yes, 

please detail: _______________________________________________________________

______________________________________________________________________________


List any areas of concern you have regarding your child and what you would 

like to see addressed in the home program. ___________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Please mail this form along with the deposit fee to:

Behavioral Intervention Services, Inc.
Huntsville, Alabama 
P. O. Box 4416
Huntsville, AL 35815

If you have questions please call (256) 527-8061.

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