Intake Form Child/Youth/Young Adult Information * First Name Last Name Date of Birth * MM DD YYYY Height / Weight (estimate is fine) * Primary Care Physician (include PCP's name and practice) * Primary Caregiver's Information * First Name Last Name Relationship to Child/Youth/Young Adult * Email * Phone * (###) ### #### Address, City, State, Zip * Employment (include company name and job title) * How did you hear about Nisar? (referral source) * Do we have verbal permission to contact other professionals for intake information? * Yes No Services Requested * Individual IBHS Group IBHS Written Order (only) Please list everyone who lives in Child/Youth/Young Adult's home. * Include name, relationship, and age of each resident. Does Child/Youth/Young Adult have children? * Yes No Any pets in the home? If yes, please list. * Any weapons in the home? If yes, please list. * Please list immediate family members who do NOT live in the home. * Include name, relationship, and age of each family member, as well as custody status if applicable. For those who will be involved with treatment, please also include email, phone, and address. Please describe any concerns about Child/Youth/Young Adult's peer interactions? * Does Child/Youth/Young Adult engage in any structured community, school, and/or religious activities? (e.g. baseball, book club, dance, etc.) * Child/Youth/Young Adult's School * School District * Grade (current or entering) * Does Child/Youth/Young Adult have... * IEP 504 ASD-Life Skills Classroom Not sure None Any detentions, suspensions, and/or expulsions? * Yes, detentions Yes, suspensions Yes, expulsions No Any refusal to go to school? * Yes, often Yes, sometimes Yes, specifically on Mondays after a long weekend/holiday break No Any other school concerns? If yes, please explain. * Has Child/Youth/Young Adult been a WITNESS to domestic abuse? * Yes No Not sure (adopted) Has Child/Youth/Young Adult been a VICTIM of domestic abuse? * Yes No Not sure (adopted) Describe Child/Youth/Young Adult's strengths. * Does Child/Youth/Young Adult currently receive (or have plans to receive) any of the following therapies? Check all that apply. * Speech Therapy (ST) Occupational Therapy (OT) Physical Therapy (PT) None Did Child/Youth/Young Adult receive therapies IN THE PAST? Check all that apply. * Speech Therapy (ST) Occupational Therapy (OT) Physical Therapy (PT) None Do any other immediate family members receive services? If yes, please explain. * Does Child/Youth/Young Adult take any medications? If yes, please list. * Any history of psychiatric/medical hospitalizations? If yes, please explain. * Any CYF involved? * Yes, right now Yes, previously (case closed) No, never Any display of these behaviors or risk factors? * Harm to self Elopement Curfew violations Property destructions Defiance Lying Verbal aggression Attention seeking Transition issues Safety issues Tantrums Hyper / impulsive / inattentive Irritable Depressed Sleeping concerns: too much, not enough Toileting concerns Eating concerns Pica (eating non-foods) None Any communication concerns or delays (e.g. use of assistive devices, echolalia, etc.)? If yes, please explain. * Any ASD / self-stimming behaviors? * Rocking Hand flapping / arm flapping Scripting Sounds (non-verbal) None Any perseveration or intense interests? If yes, please explain. * Any abuse history? * Substance Alcohol Smoking Other Thank you!
