Initial Client Report: Family information, background, history and preference assessment.

Initial Client Intake and Report

Assignment Description and Rubric

Note – this assignment requires approximately 5 hours of field based observation. You may use intake forms and assessments required by your field placement or use ones that you find from the internet. You will also be required to gather observational and interview data. You may use the PENT information to locate forms and potential interview questions but you are not obligated to use them and can use forms that apply to your employer or your state. This assignment requires signed consent from a parent.

*You must write a report in your words and your voice. Plagiarizing an existing report will result in immediate disciplinary action that can result in dismissal from the program. Plagiarism determined after program completion can result in the rescinding of your degree or certificate and notification to the BACB.

Child Name: (pseudonym only. Assignment will be returned if identifying information is included) the identity of the child and family)

Responsible Party Name: Relationship to client:

Contact Phone Number: Contact email:

Preferred method for contact:

Responsible Party Name: Relationship to client:

Contact Phone Number: Contact email:

Preferred method for contact:

Note: Names and identifying information have been changed to protect the client’s confidentiality.

Client/child DOB and age at present referral:

Health care provider: Phone Number:

Other current service providers:

Role: Name: Phone:

Role: Name: Phone:

Role: Name: Phone:

Primary language:

Living Arrangement:

Initial concern as presented by referring person/agency:

Current educational/early care placement concerns:

Cultural considerations:

History:

Birth history:

Medical history/concerns:

Age at initial behavioral/developmental concern:

Description of initial concerns:

Response to initial concerns: (e.g., who was notified, follow-up action taken)

History of treatment/intervention:

Current Concerns / Referral assessments

Dates, location and results of intake observations:

Files reviewed:

Assessments and results:

Observational data gathered:

Interview information (not already reported):

Summary

Client Description – Write a concise summary of the client’s demographic information including early history, current living situation, birth history, known trauma and medical history.

Educational/Intervention history – Write a concise summary of relevant intervention or educational experiences including intervention.

Child preferences – Write a description of child likes, interests and preferences as determined by the different assessments, interviews and observations that were conducted as part of the intake. Be sure to reference where the information came from.

Child/client strengths – Write a concise description of the client/child’s strengths as determined by the different assessments, interviews and observations that were conducted as part of the intake. Be sure to reference where the information came from.

Presenting concerns – Write a concise description of the client/child’s concerns as determined by the different assessments, interviews and observations that were conducted as part of the intake. Be sure to reference where the information came from.

Priorities for intervention – List and rationalize the top three goals that emerged as determined by the different assessments, interviews and observations that were conducted as part of the intake.

Justification for goals – Use your readings and goal selection tools to justify the top three selected goals.

Collaboration/ Supporting Interventions – Discuss which collaborative partners should be involved in intervention efforts (e.g., parents, extended family members, schools, child care providers, health care providers, related service providers?). What support services should be provided to the identified collaborative partners?

Cultural considerations – What accommodations will be provided based on the families identified cultural differences and /or practices?

Rubric