I. How Did You Hear About Us?

Name of Person Making Request

II. Client's Information

III. Client School Information

IV. Diagnosis Information

Name of Professional Who Gave Diagnosis:

V. Behavioral Diagnosis

VI. Primary Medical Diagnosis

Current Medication, if any

VII. RBT Preference

VIII. Other Services Client Is Currently Receiving

IX. Checklist Of Available Intake Documents

X. Proposed Service Schedule

Direct Therapy

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

XI. Intake Assessment Meeting