About this template
Streamline your practice intake workflow with this comprehensive Behavioral Consulting Client Intake Form. Designed specifically for behavioral consultants, therapists, and child specialists, this template helps you gather crucial background information from parents and guardians before your initial consultation.
The form covers all essential areas including child demographics, household members, educational history, IEP status, current medications, daily routines, and specific behavioral concerns or triggers. By capturing this detailed background data in advance, you can prepare thoroughly for sessions and focus on developing effective intervention strategies right from day one.
Built on Google Forms through Doc2Form, this template is entirely customizable to fit your practice's specific assessment needs. Share a simple link with parents and have all responses automatically organized in a connected Google Sheet for easy review and secure record-keeping.
Key features
- Collect detailed child background and developmental history in one step
- Gather medical, medication, and IEP status securely
- Identify specific behavior triggers, frequencies, and previous strategies
- Organize parent contact info and emergency contacts automatically
- Fully customizable and ready to deploy instantly via Google Forms
Use cases
- Initial intake for new behavioral therapy or consulting clients
- Pre-consultation assessments for child development specialists
- Gathering educational and behavioral history for school-age children
- Documenting parent goals and intervention preferences prior to sessions
What this form collects
- Child's Full Name (Short answer)Enter the child's first, middle, and last name.
- Today's Date (Date)Select today's date.
- Child's Date of Birth (Date)Enter the child's birth date.
- Gender (Multiple choice)Select the child's gender.
- Current Age and Grade (Short answer)Specify the child's current age and school grade.
- Home Address (Paragraph)Enter your primary residential address.
- Parent / Guardian 1 Information (Paragraph)Provide contact details for the primary parent or guardian.
- Parent / Guardian 2 Information (Optional) (Paragraph)Provide contact details for a secondary parent or guardian if applicable.
- Emergency Contact Information (Paragraph)Provide the name, phone number, and relationship of someone to contact in an emergency if parents cannot be reached.
- Educational Background (Paragraph)List the schools attended, years attended, and general academic performance.
- IEP or 504 Plan Status (Multiple choice)Does the child currently have an Individualized Education Program (IEP) or 504 plan?
- Household Members and Ages (Paragraph)List all individuals living in the household and their ages.
- Current Medications and Supplements (Paragraph)List any daily medications, dosages, and when they were started.
- Behavior Concerns Overview (Paragraph)Describe the primary behaviors or challenges that prompted you to seek consultation.
- Behavior Triggers and Frequency (Paragraph)When do these behaviors most often occur, and how frequently do they happen?
- Previously Tried Strategies (Paragraph)What strategies or interventions have you already tried, and how effective were they?
- Primary Consultation Goal (Paragraph)What is the main outcome you hope to achieve through our behavioral consulting sessions?
- Parent / Guardian Signature (Short answer)Please type your full name to confirm authorization and accuracy of the information provided.
FAQ
How do I share this intake form with parents?
Once you convert and open the template in Google Forms, simply click the 'Send' button to share the form link via email, text, or post it directly on your practice website.
Can I customize the questions on this intake form?
Yes! Since the template lives in your Google Drive, you can easily add, remove, or edit any questions to match your exact consulting practice requirements.
Where is the submitted intake data stored?
All client responses are saved directly into your secure Google account and can be automatically linked to a Google Spreadsheet for seamless tracking.
Is this form template free to use?
Yes, this template is completely free to copy, customize, and use for your behavioral consulting practice.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.