aba intake under 18integrate-health.ca/forms/aba intake under 18-r.pdf · we have selected dfo we...

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Date:____________________Howdidyoulearnaboutourservices?__________________________________

PersoncompletingForm:_____________________Whatserviceareyouinterestedin?

Centre-basedABA Home-basedABA AfterschoolABA ParentingTraining BehaviouralConsultation

CLIENTINFORMATION:Name:_______________________________D.O.B____________Age______Gender: M F Other

Address:________________________________________City:________________PostalCode:___________

HealthCard#:________________________________________VersionCode:__________________

Doesyourchildhaveadiagnosisorexceptionality?(ifyes,pleaseidentify)______________________________

Ageofdiagnosis:______________

PARENT/GUARDIANINFORMATION:Name:____________________________________________RelationshiptoChild:______________________

D.O.B:______________________(Age)_______Gender: M F Other

MainContact#:_________________________________Alternate:__________________________________

Address: SameasaboveOR_____________________________City:____________PostalCode:________

Doyouhaveadiagnosisorexceptionality?_______________________________________________________

Doyouhaveafamilyhistoryofmentalorphysicalhealthconcerns?__________________________________

Married Common-law Separated Divorced Widowed-Pleaseindicatedate:_________or Single

ABASERVICESINTAKE-UNDER18

Isyourchild/youthandfamilyregisteredwiththeOntarioAutismProgram(OAP)? Yes No

Ifno,areyouchoosingtopayprivatelyforservices? Yes No

Ifyes,pleasespecify:

WehaveselectedDFO WearecurrentlyonthewaitlistforOAPservicesWearecurrentlyreceivingOAPservicesbutwishtochangeproviders

OAPFamilyServiceWorkerInformation(ifregisteredwithOAP):

Name:___________________________________________

PhoneNumber:____________________________________

Email:____________________________________________

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Email*(Wewilluseemailforimportantcorrespondence):__________________________________________PleaseaddmetoyourmaillistsothatIreceiveinformationaboutprogramsandservices: Yes No

PARENT/GUARDIAN2INFORMATION:Name:____________________________________________RelationshiptoChild:______________________

D.O.B:______________________(Age)_______Gender: M F Other

MainPhone#:__________________________________Alternate:__________________________________

Address: SameasaboveOR_____________________________City:____________PostalCode:________

Doyouhaveadiagnosisorexceptionality?_______________________________________________________

Doyouhaveafamilyhistoryofmentalhealthorphysicalconcerns?__________________________________MaritalStatus:

Married Common-law Separated Divorced Widowed-Pleaseindicatedate:_________or Single

Email*(Wewilluseemailforimportantcorrespondence):__________________________________________PleaseaddmetoyourmaillistsothatIreceiveinformationaboutprogramsandservices: Yes No

CHILDCUSTODY:Joint Sole Ifsole,withwhom?________________(Ifsolecustody,wemustreceivecourtorder)Isthischild:Natural Adopted Foster ____Dateofplacement/adoption:_______________________EMERGENCYCONTACTS(otherthanparent):Name:____________________________________________RelationshiptoChild:______________________

Maincontact#()____________________________Alternate#()_____________________________

Name:____________________________________________RelationshiptoChild:______________________

Maincontact#()____________________________Alternate#()_____________________________

Previous/currentcontactwithMentalHealthProfessionalsorSupportServices:

NameofAgency ProfessionalInvolved TypeofSupport(medication,

counselling,etc.).

DateandDurationofTreatment

Wasiteffective?

Areyoucurrentlyonanywaitlistsforservices?:_________________________________________________

HowfamiliarareyouwithwhatABAservicesentail? Veryfamiliar Somewhatfamiliar Notatallfamiliar

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FamilyContacts Biological Step/Half Adoptive Foster/GuardianParent/Guardian□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Phone

Phone Phone Phone

Work/Occupation

Work/Occupation Work/Occupation Work/Occupation

Parent/Guardian□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Phone

Phone Phone Phone

Work/Occupation

Work/Occupation Work/Occupation Work/Occupation

Sibling1□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Sibling2□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Sibling3□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Sibling4□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Sibling5□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Sibling6□M□F□Other

Name(age)

Name(age) Name(age) Name(age)

Wholivesinthehome(names,relationshipandages)?Doanysiblingsorcousinshaveadiagnosisorexceptionality?Ifyes,whatageweretheydiagnosed.Ifchildlivesinmorethanonehomepleaseprovidedetailsonlivingarrangements?CHILD’SEDUCATION:NameofSchool:__________________________________SchoolBoard:_____________________________

SpecialEducationClass IEP(IndividualizedEducationPlan) ResourcePeriodEducationalAssistance Tutoring Other

Pleaseattachmostrecentcopyofyourchild’sIEP

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CHILD'SDEVELOPMENTALHISTORY: PrenatalandBirthEvents:Pregnancycomplications?(bleeding,excessvomiting,medication,infections,x-rays,smoking,alcohol/druguseetc.) DeliveryComplications? ToiletTraining:(AgeReached)BowelControl:DayNightBladderControl:DayNight CurrentConcerns/Goals: SexualDevelopment/Genderidentity: CurrentConcerns/Goals: MotorDevelopment:(Pleasedescribeanyconcernsorgoalsforyourchild’smotorskilldevelopment) Doesyourchildfavourahandwhenwriting,orafootwhenplayingsports(e.g.,kicking)? LanguageDevelopment:(pleasedescribeanyconcernsorgoalsforyourchild’slanguagedevelopment) SocialDevelopment:(pleasedescribeanyconcernsorgoalsforyourchild’ssocialdevelopment) Currentpeerinteractions: Specialinterests/hobbies:

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EATINGBEHAVIOURS:Eatshealthyfoods: Yes No Eatsmostlyjunkfood: Yes NoOver-eats: Yes No Doesnoteatenough: Yes NoFeeding: Orallyfed G-tubefed YesGJ-tubefedDifficultyswallowingfoods(i.e.maycough,gag,vomitduringorbetweenmeals): Yes NoIfyespleaseexplain,______________________________________Gagswhennewfoodsareintroduced: Yes No

Drinksliquidfrom: Sippycup Bottle RegularCupHaschallengesdrinkingliquids: Yes NoTypesofliquidsconsumed:__________________

Exhibitsinappropriatebehavioursatmealtimes: Yes NoIfyes,pleaseexplain:________________________________________________________________________DietaryRequirements(selectallthatapply):

Regular,dietastoleratedLactose-IntolerantVegetarian:

Semi-Vegetarian(nobeeforpork) Lacto-Ovo(nobeef,pork,chicken,seafood,orfish) Vegan(nomeats,eggs,ordairy) Other-Pleasespecify:__________________________________

GlutenFreedietPickyEater(pleaseexplain):______________________________________________Otherfoodrestrictions:___________________________________________________________________

SLEEPBEHAVIOR:Hasaconsistentbedtimeroutine Yes NoBedtime:_________Wake-time:_________Goestobedandfallsasleepwithnodelay: Yes NoIfyes,pleaseexplain:________________________Fallsasleepwithoutassistance: Yes NoFallsasleepwithassistanceofcaregiver/parent: Yes NoRemainsasleepthroughoutthenight: Yes NoWakesupseveraltimes: Yes NoIfyes,howmanytimes?____________________________________Pleasedescribehowtogetyourchildtofallbackasleep:____________________________________________Pleasedescribewhatyourchilddoesifhe/shewakesupinthemiddleofthenight:__________________________________________________________________________________________Napsduringtheday Yes NoNaptime:_________Duration:_________

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PROBLEMBEHAVIOURINFORMATIONProblemBehaviour(Describewhatyourchilddoes/says)

Frequency(hourly,daily,weekly)

Duration(howlongthebehaviorlasts)

SeverityMild–disruptivebutlittleriskModerate–somewhatsignificantdamage.Severe–verysignificantthreattohealthorsafety

Describehowyourchildcalmsdown

Isthecalmingtechniqueeffectivebothshortandlongterm?

Pleasedescribethesituationsthattheseproblembehavioursaremostlikelytooccur:________________________________________________________________________________________________________________________________________________________________________________________________________Pleasedescribethesituationsthatthebehavioursareleastlikelytooccur:_________________________________________________________________________________________________________________________________________________________________________________________________________________Pleaselistthetechniquesimplementedinthepasttodecreaseproblembehavioroccurrences:______________________________________________________________________________________________________Pleasedescribehowyourchildrequestsforitems:__________________________________________________________________________________________________________________________________________Pleasedescribeyourchild’sabilitytoanswerquestions:____________________________________________

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CHILD’SMOOD:Howwouldyoudescribeyourchild’spersonality? Doesyourchildhaveanyfears/phobias? Yes NoIfyes,pleasedescribe: Howdoesyourchildexpresstheirfeelings?:

CHILD'SHEALTHINFORMATIONANDHISTORY:AnaphylacticAllergies:

Doesyourchildhaveanylifethreateningallergies? Yes No

Ifyes,pleaselisttheanaphylacticallergies:______________________________________________________

Typeofauto-injector:EpiPen: Junior AdultAllerject: Junior Adult

Ifyourchildhasalife-threateningallergyyouMUSTcompletetheANAPHYLAXISEMERGENCYPLANFORMANDADMINISTRATIONOFMEDICATIONFORM. AllOtherAllergies:Doesyourchildhaveanynonlife-threateningallergies? Yes No

Ifyes,pleasecompleteinformationbelow:

Allergy:Drugs/Food/Environment

ReactionorSymptoms:AllergyorSideEffect

RecommendedResponse

Doyouadministermedicationforallergicreactions? Yes No

Ifyes,pleasecompletetheADMINISTRATIONOFMEDICATIONFORM.

HealthConditionsorComplications:

Doesyourchildhaveanycurrenthealthcomplicationsorconditions?

Ifyes,pleaseexplain:

_________________________________________________________________________________________

__________________________________________________________________________________________

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MEDICATIONS–CURRENT

PASTMEDICALHISTORY: No Yes1. MAJORILLNESSES Year Illness Treatment Result

No Yes2. SURGERY Year TypeofSurgery ReasonforSurgery Result

No Yes3. HOSPITALIZATIONS Year Illness Treatment Result

OtherHealthIssues(checkallthatapply):Asthma Arthritis BowelIssues BleedingDisorder

Concussion:Date:_________

Diabetes ChronicEarInfections EarTubes

ChronicNoseBleeds

FrequentColds HeartCondition Headaches

HearingDifficulties HearingAids HighBloodPressure SeizuresSight/VisionDifficulties SinusTrouble SkinConditions/Rashes ToothachesOther:

_____________________Other:

__________________Other:

_____________________Other:

__________________

NameofMedication Dosage #Times/day OtherDirections:

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No Yes4. INJURIES/ACCIDENTS Year Injury

No Yes5. PHYSICAL/SEXUALABUSE Year RelevantInformation

IMPORTANTINFORMATION:Pleasedescribeyourchild’sstrengthsandinterests(extracurricularactivities,hobbies,thingstheyenjoy):

Whatareyourgoalsforyourchild/Whatareyouhopingtoachieve?

Pleasedescribeanystressors/triggersandwhenyourchildisexperiencingdifficulties:

Pleasedescribeyourchild’smostpreferitems/activitiesPleasedescribeyourchild’sleastpreferreditems/activities

Isthereanythingelseyouwouldlikeustoknow?

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Pleasecheckanyareasofconcernthatapplyandprovidedetails

☐Delaysinfinemotorskills(printing,grippingitems,usingscissors)____________________________________________________________________________________________________________________________ ☐Dailyliving/self-careskills(dressing,toileting,hygiene,eating)______________________________________________________________________________________________________________________________ ☐ Sensoryprocessingchallenges(overly/undersensitive)____________________________________________________________________________________________________________________________________ ☐Grossmotorskills(handeyecoordination,balance)_____________________________________________________________________________________________________________________________________ ☐Anxiety,depressionormentalhealthchallenges__________________________________________________________________________________________________________________________________________ ☐ Schoolperformance(attention,organization,remainingseated,academicdifficulties)___________________________________________________________________________________________________________ ☐ Socialskills(maintainingrelationships,socialboundaries,initiatingconversation)_______________________________________________________________________________________________________________ ☐ Communication(languagedelays,currentlyusingcommunicationtools)____________________________ __________________________________________________________________________________________ ☐Family/siblingrelationships_________________________________________________________________☐Regulationofemotions/irregularmood________________________________________________________ ☐ Developmental/Learningdelays______________________________________________________________________________________________________________________________________________________

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ThankyouforyourinterestinIntegrateHealthServices.Pleasebeawarethatallclientinformationwillbestoredasconfidentialclinicrecords.Whereassessmentservicesareprovided,informationsharedwillbecomepartofaconsultletter,whichwillbeforwardedtotheclientand/orparent(s)/guardian(s)andreferringphysician.Anyadditionalinformationsharedoutsidetheclinicwouldrequirethewrittenpermissionoftheclientorparent(s)/guardian(s)(whentheclientisundertheageof16orunabletoprovideconsent).CONFIDENTIALITY:Therearebylaw,certaincircumstancesinwhichconfidentialitycannotbemaintained.Thesesituationswould include: (1) suspectedchildabuseorneglect (2)circumstanceswhere theclienthasbecomeadangertothemselvesorothers,(3)wheninformationhasbeensubpoenaedbythecourt.Shouldyouhaveanyquestionsaboutthe limitsofconfidentiality,pleasecontactan IntegrateHealthServicesteammember.PARENTALCONSENT:All childrenunder16 yearsof age requireparental/guardian consent to access services at IntegrateHealthServices.Clientsovertheageof16(whoarebelievedtobecapableofunderstandingthedetailsofinformedconsent)areabletosigntheirownconsentforservices.APPOINTMENTS:Pleaseensureyouarriveontimeforyourscheduledappointment,asweareunabletoextendyoursessiontime.Noshowappointmentswillbesubjecttoahalf-sessioncharge.WAIVER:Mychild'sphotograph/visuallikenessmaybedisplayedatIntegrateHealthServicesoffice(forthepurposesofclientawards/recognition).Igiveconsent☐Idonotgiveconsent☐INTEGRATEHEALTHSERVICESTEAMAPPROACH-CIRCLEOFCARE:Integrate Health Services is a multi-disciplinary team working in partnership with The Kids Clinic. We arecomprisedofvarioushealthprofessionalsandincircumstanceswhereitisbelievedtobeinthebestinterestoftheclient,pleasebeawarethatpersonalhealthinformationmaybesharedamonghealthcareprovidersatIntegrate Health Services and Kids Clinic. Information shared will be determined on a case-by-case basisdependant upon the needs of the individual client(s). *When you access Speech Therapy or OccupationalTherapyServices,pleasebeawarethattheinformationyouprovidetoIntegrateHealthServicesissharedwithourpartners,SpeechTherapyCentresofCanadaandAshleyRegoOccupationalTherapyServices.Bysigningthis form, you are consenting to all services provided through Integrate Health Services, includingthoseaffiliatedwithSpeechTherapyCentresofCanadaandAshleyRegoOccupationalTherapyServicesandunderstandthatthesamelimitsofconfidentialityapply.

INFORMEDCONSENT

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CONFIDENTIALITYWITHCHILDREN:Inorderforchildrenandadolescentstofeelsafeandbeabletoidentifyanddiscussconcerns,theymustfeelasense of privacy and some control over the information they share. At Integrate Health Services, it is ourresponsibilitytohonourandrespectthechildoradolescent’sconfidentiality-thisiscrucialtodevelopingtrustandachievingpositiveoutcomes.Weunderstandthatparent(s)/guardian(s)wanttobeupdatedregardingtheassessment/counselling process and be made aware of any information that would assist them in bettersupporting their child/adolescent. We will always seek permission from the child / adolescent to sharerelevantthemesordetailswhereitisdeterminedtobeintheirbestinteresttodoso.Ifotherfamilymembersmayparticipateincounsellingsessions,pleaselistthembelow:

Name RelationshipDateofBirth

1._____________________________ _________________________________________________2._____________________________ _________________________________________________3._____________________________ _________________________________________________

IntegrateHealthServicesprovidesthefollowingsupportprogramsandservices:

• PsychologicalAssessments• CounsellingServices• ArtTherapy• BehaviouralTherapy-AppliedBehaviourAnalysis(ComprehensiveandFocusedABA)• BehaviourConsultation• Child/Youth/AdolescentGroupPrograms• ParentSupportandSkillsTraining• EducationServices• SpeechandLanguageTherapy(throughourpartnershipwithspeechtherapycentresofCanada)• Occupational Therapy Services (through our partnership with Ashley Rego Occupational Therapy

Services)

I, ___________________________________________________________________ have reviewed the aboveinformation and fully understand the details of informed consent. An Integrate Health Services team member hasansweredanyquestionsIhad.Atthistime,Imakeaninformedchoice(formyselforchild)toaccessservicesatIntegrateHealthServices.*PleaseNote:Childrenenrolling inagroupprogrammusthave theability tomanage ina3:1or4:1ratio (dependantuponprogram). Ifyouhaveconcernsaboutsuitabilityorwould liketodiscussoptions foradditionalsupport,pleasecontactus.___________________________________ ______________________________ _____________________ClientName Signature(ifover16) Date

CLIENTCONSENT:

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Iftheclientisunder16years,parent/guardianconsentisrequired(BOTHparentsinthecaseofajointcustody)

____________________________________________________________ _______________________Parent/GuardianName Signature Date

____________________________________________________________ _______________________Parent/GuardianName Signature Date

____________________________________________________________ _______________________WitnessName WitnessSignature Date

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*Tobecompletedforclientundertheageof16priortoaccessingservicesifparentsareseparatedordivorced

ThankyouforaccessingservicesatKidsClinic/IntegrateHealthServices.Pleasebeawarethatallchildrenundertheageof16requireparental/guardianconsenttoaccessservices.Insituationsinwhichparents/guardiansareseparatedordivorcedandthere is jointcustody(even if thechild livesonlywithoneparent),bothparentsmustprovidesignedconsentbeforeachildcanaccessservices.

It is my/our understanding that accessing services are intended to support my/our child’s overall well-being. Thepurposeofaccessing these services is tobenefit thechild involvedandnot to collectorgather information for courtpurposes. *It isparent’sresponsibilitytoadvisetheclinicofanychangestochildcustody,accessto information,etc.andtoprovidethesupportingdocumentation.

_____________________________________________________________ ________________Parent/GuardianName SignatureDate

_____________________________________________________________ ________________Parent/GuardianName SignatureDate

_____________________________________________________________ ________________

Parent/GuardianName WitnessSignatureDate

InCircumstancesofSoleCustody:I,(parent/guardianname)_______________________________________________beingthesolecustodialparentofchild’sname_______________________________________________________,D.O.B.:________________________ herebyconsenttoassessmentorsupportservicesforthischild,atKidsClinic/IntegrateHealthServices.Isthereacurrentcourtorderregardingcustody/accessforthischild� Yes� No(thismustbeprovidedtoclinic)Doestheagreementallownon-custodialparentaccesstoinformation?� Yes� NoThiscustodialarrangementis:☐Permanentdisposition☐Interimdispositionuntil(date)________________________

InCircumstancesofJointCustody:I,_____________________________________________and______________________________________________parent/guardiannameparent/guardiannamebeingjointcustodialparents/guardiansof(child’sname)_________________________________________________, D.O.B.: __________________ hereby consent to assessment support services for this child, at Kids Clinic/IntegrateHealthServices.

PARENTALCONSENT(CustodyAgreement)