Behaviour Therapy Intake Form

This form is being completed by *

Childs First Name *

Last Name *

DOB *

Gender *

Other - please specify

Main Contact Person

Parent/Guardian Full Name *

Relationship to Child *

Mobile *

Email Address

Address *

Suburb *

State *

Postcode *

Other Diagnosis

Funding *

PrivateNDIS Self ManagedNDIS Plan Managed

School/Preschool *

Areas of Concern

Behavioural concerns *

Locations these behaviours typically occur (select all that apply):

Home

Childcare/preschool/school

Community e.g. shops, playgrounds

Other home locations e.g. second caregiver home

Other people’s homes

Intervention sessions e.g. OT, Speech, Psychology

Other

Other - please specify

People the behaviours occur in the presence of? *

Approximate start date of the behaviours *

Do these behaviours impact on the completion of daily activities (for the child or others)?

Yes

No

Do these behaviours present a significant physical risk to the child or others?

Yes

No

Does the child have an established way to communicate their wants and needs e.g. verbal,PECs, sign that can be understood by most adults and children?

Yes

No

Does the child have predictable and consistent interests?

Yes

No

Previous Assessments

Previous assessments by any relevant health professionals *

Please list assessments completed

Previous Intervention

Previous therapy by any relevant health professionals *

Please list previous intervention

Additional Comments

Thank you for completing an intake form with MMT. We hope to support you soon!