INTAKE FORM
NAME OF CLIENT: 
AGE:
DOB:
DATE:
NAMES OF IMMEDIATE FAMILY MEMBERS:
MARITAL STATUS: (circle) SINGLE, MARRIED, SEPARATED, DIVORCED
EMAIL (to confirm receipt of this form):
ADDRESS: Street:
City:
State:
Zip code:
PHONE: (H)
(W) (CELL)
NAME OF SCHOOL:
GRADE (or equivilant):
WHAT KIND OF CLASS IS STUDENT IN: (For children and adolescents only.
Circle all that apply:)
- REGULAR EDUCATION/FULLY MAINSTREAMED
- REGULAR ED WITH SUPPORTS
(AIDE, 504 PLAN, OTHER:) - RESOURCE ROOM FOR SUBJECTS:
- SELF-CONTAINED CLASS
- SPECIAL ED SCHOOL
- DISCRETE TRIAL OR ABA HOME PROGRAM
- OTHER:
WORK STATUS (For adult clients only. Circle all that apply)
- CURRENTLY EMPLOYED AS A
- LOOKING FOR EMPLOYMENT AS A
- INVOLVED WITH THE OFFICE OF VOCATIONAL REHABILITATION TO FIND EMPLOYMENT
- WORKING IN A SHELTERED WORKSHOP
- GOING TO COLLEGE AT
- GETTING SPECIFIC VOCATIONAL TRAINING AT
ANY FORMAL DIAGNOSES:
ANY MEDICATIONS (dose and frequency):
SPECIFIC CONCERNS: (State your specific concerns and those expressed by
teachers and others.)
ANY HISTORY OF SUICIDAL THOUGHTS OR GESTURES (words or actions):
ANY AGGRESSIVE BEHAVIORS (e.g., hitting, biting, or verbal threats):
POSSIBLE SERVICES DESIRED: Circle desired services:
| 1. SOCIAL SKILLS NEEDS ASSESSMENT | 2. INDIVIDUAL OR FAMILY THERAPY |
| 3. DIAGNOSTIC EVALUATION | 4. SOCIAL SKILLS: GROUP OR INDIVIDUAL |
| 5. SCHOOL CONSULTATION FOR SOCIAL OR BEHAVIORAL CONCERNS | 6. HOME BEHAVIOR PROBLEM ASSESSMENT, DEVELOPMENT OF A BEHAVIOR PLAN AND PARENT TRAINING |
| 7. PEER SENSITIVITY TRAINING | 8. SCHOOL INSERVICE TRAINING |
AVAILABILITY FOR APPOINTMENT TIMES: (the more times you list, the easier
it will be to make an appointment)
REFERRAL SOURCE:
OTHER INFO:
Mail all forms to:
Jed Baker, Ph.D.
29 Collinwood Rd.
Maplewood, NJ 07040
