Has the client ever been admitted to a hospital/treatment center for psychiatric, behavioral, or crisis situation? Yes No If yes, please explain. □ □ Please summarize the hospital/treatment treatment and effectiveness of treatment: center’s Are there any medical conditions that need to be considered when client is in ABA therapy or speech therapy: Yes No If yes, please explain. □ □ Therapies and Services What other services are your child currently receiving? Please include all services, including school based. Service/Therapy Location Verbal Behavior/ABA services □ Early Intervention services □ Speech/language therapy □ Occupational therapy □ Physical therapy □ Developmental therapy □ Other______________________ □ Please describe the results of these therapies in regards to success in achieving goals. What are your immediate goals for your child? ______________________________________________________________________________________ What level of commitment are you willing to make at home in order for your child to achieve these goals?
Has the client ever been admitted to a hospital/treatment center for psychiatric, behavioral, or crisis situation? □ Yes □ No If yes, please explain. Please summarize the hospital/treatment center’s treatment and effectiveness of treatment: Are there any medical conditions that need to be considered when client is in ABA therapy or speech therapy: □ Yes □ No If yes, please explain. Therapies and Services What other services are your child currently receiving? Please include all services, including school based. Service/Therapy Location □ Verbal Behavior/ABA services □ Early Intervention services □ Speech/language therapy □ Occupational therapy □ Physical therapy □ Developmental therapy □ Other______________________ Please describe the results of these therapies in regards to success in achieving goals. What are your immediate goals for your child? What level of commitment are you willing to make at home in order for your child to achieve these goals? ______________________________________________________________________________________