Client Information Form (Page 2 of 2) in pdf

Client Information Form Page 2

Client #:_________

Today’s Date:_____________

Does your child engage in any of the following behaviors (check all that apply)?

Behavior

Yes

Frequency, comments

Property destruction

Physical aggression

Verbal aggression

Noncompliance

Elopement

Self-injurious behavior

Other:

Please describe how your child interacts with peers: _____________________________________________________

__________________________________________________________________________________________________________________

What are your child’s preferred activities, snacks, and objects?___________________________________________

__________________________________________________________________________________________________________________

What are your child’s non-preferred activities, snacks, and objects?_____________________________________

__________________________________________________________________________________________________________________

What age group does your child prefer to play with or typically engage? ________________________________

Does your child (check all that apply):

Require prompting to interact with other children

Resist when asked to interact with other children

Have difficulty participating in a group

Play alone

Take turns

Become upset when others do not play in the manner he/she wanted

Engage in perseverative/repetitive behaviors

Engage in parallel play

Client Information Form Page 2