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ADOS Assessment Form
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INTAKE FORM
PARENT INFORMATION
CLIENT INFORMATION
Is your child toilet-trained?
Yes
No
Does your child nap?
Yes
No
LOCATION FOR SERVICES
Cedar Park
South Austin
REFERRAL INFORMATION
DIAGNOSTIC INFORMATION
Diagnosed?
Yes
No
Other existing diagnoses?
Yes
No
INSURANCE INFORMATION
SERVICE HISTORY (Please select all that apply)
Current Services
Speech and Language Therapy
Behavior Intervention Services
Occupational Therapy
Physical Therapy
ABA Therapy
Previous Services
Speech and Language Therapy
Behavior Intervention Services
Occupational Therapy
Physical Therapy
ABA Therapy
Does your child attend school?
Yes
No
Current IEP/504 Plan at School?
Yes
No
SOCIAL AND BEHAVIORAL HISTORY
Please select any of the following behaviors that your child engages in
Aggression
Difficulty regulating emotions
Deficits in Attention OR Hyperactivity
Self-stimulatory OR Repetitive behaviors (i.e. hand-flapping, lining up objects, spinning, etc.)
Repetitive vocal/verbal behaviors
Tantrums
Self-injurious Behaviors
Rituals/Routines/Insistence on Sameness
PLEASE CHECK THE DAY/TIME SLOTS AVAILABLE FOR THERAPY (all applicable)
AM (8:30-12:30)
Monday
Tuesday
Wednesday
Thursday
Friday
PM (1:00-5:00)
Monday
Tuesday
Wednesday
Thursday
Friday
SUBMIT
Thanks for submitting! We will be in touch soon.
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