Behavioral Assistant Intake Form

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Behavior Assistant's Name: *

Behavior Assistant's Email: *

Youth/Adolescent's Full Name: *

Today's Date: * +

IIC's Name: * 🛈

IIC's Phone/Email: * 🛈

Youth's Diagnosis: * 🛈

It is recommended for BAs to contact the assigned IIC and gather the following information.

Clinical summary from IIC regarding youth: *

IIC recommendations for BA: *

This portion is completed by the BA during the initial session with the youth/family.

What problematic behaviors is the youth currently engaging in? *

When did each behavior start and how often? *

What was the triggering event to the behaviors? *

What currently triggers the youth? *

What environment does the youth exhibit these behaviors (home, school?)? *

Who currently lives in the home? *

What are the current family dynamics within home? *

Is there any history or current mental health issues within the home? *