Centre-Based Online Intake Form

Please confirm the following before completing the intake document

I am aware that SBC provides Applied Behaviour Analysis (ABA), an evidence-based therapy in compliance with the Behaviour Analytic Certification Board (BACB)

For centre-based therapy my child is under the age of 6 years of age

I am aware that I will be accessing Centre-Based therapy for my child, in Saskatoon

SBC works in a semester system for a minimum of 3-month time commitment with weekly sessions ranging from 6-15 hours per week. Intensity recommended based by Board Certified Behaviour Analyst/Board Certified Assistant Behaviour Consultant (BCBA/BCaBA)

Parents are required to participate and collaborate with the Behaviour Team for optimal therapeutic outcomes

SBC will provide consultation services in: schools, daycares, community environments and rural and remote areas based on staffing availability and complexity of needs

Today's Date

Year

Month

Day

Parent/Caregiver name

Email

Phone

Additional Parent/Caregiver name (if applicable)

Additional Caregiver Email

Additional Caregiver Phone

Child's Name

Preferred/Nickname (if applicable)

Child’s date of birth

Year

Month

Day

Gender/Sex

Current Child’s Age

Diagnosis

Date of diagnosis (if possible)

Year

Month

Day

Prescribed Medications

Type

Time of Day Prescribed

Other Health Concerns

Allergies

Siblings

Siblings Age

Primary Language Spoken at home

Secondary Language Spoken at home

Home Address:

Home Address

Country/Region

Address

City

Zip / Postal code

Dates/Times Available for Therapy—not your actual therapy time

9:00am-12:00pm

1:15pm-4:15pm

Which days of the week your child attends service providers

School Your Child Currently Attends

School Schedule

Does your child have a designated 1:1 EA or shared EA?

Yes

No

Currently in the application process

Daycare Child Currently Attends

Daycare Schedule

Does your child have a designated 1:1 EA or shared EA?

Yes

No

Currently in the application process

Does your child nap?

Yes

No

Nap Schedule

What are some of your child’s strengths or current interests? (list 3):

Areas of Concern: Check all that apply

Behaviour management (teaching replacement skills in lieu of hitting, biting, properly destruction, self-harm, etc.)

Sleeping (independently at night, reduced early wakes, etc.)

Spoken Language (establishing a means to communicate their needs and wants)

Understanding Language (following instructions, comprehension, etc.)

Feeding/Eating (increasing your child’s variety of foods consumed, teaching your child to chew, using a straw, self-feeding etc.)

Toileting (increasing independence with toileting skills such as eliminating in the toilet, transition from diapers to underwear, etc.)

Motor Skills (gross motor: bike riding, getting dressed, etc or fine motor skills: pencil grip, buttons, zippers, etc.)

Play Skills (sharing, turn taking, parallel play, independent play, group activities, waiting turns)

Pre-Academic Skills: circle time, letter/number/colour identification, sitting at a desk, exposure to academic tasks such as colouring, matching, sorting, etc.

Areas of Concern: During a 3 month therapy semester, what would be considered a main parent priority for your family? (i.e., develop a means of communication, reduce challenging behaviours, etc)

How soon would you like to start services? *not guaranteed as SBC may have a waitlist

As soon as possible

In the next 3 months

In the next 6 months

Other

Is there anything else that you’d like us to know?

Centre-Based Online Intake Form

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