Centre-Based Online Intake Form

Please confirm the following before applying for services

Program Overview

I understand that Saskatchewan Behaviour Consulting (SBC) provided Applied Behaviour Analysis (ABA) - an evidence-based therapy in line with the Behaviour Analyst Certification Board (BACB)

I am aware that I am applying for centre-based therapy for my child in Saskatoon

Eligibility

I confirm that my child is under the age of 6, which is required for centre-based therapy

Therapy Commitment

I understand that SBC follows a semester system, requiring a minimum of 3-month commitment

I acknowledge that weekly sessions will range from 6 to 15 hours

Additional Services

I understand that SBC may provide consultation services in schools, daycares, community spaces, worshops, parent training, depending on staffing and individual needs.

Today's Date

Month

Day

Year

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

Month

Day

Year

Gender/Sex

Current Child’s Age

Diagnosis

Date of Diagnosis (if possible)

Month

Day

Year

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

Current Service Providers

Which days of the week does your child attend other service providers

Previous Service Providers- participated in therapy in the past 6 months

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?

How did you hear about SBC?

Centre-Based Online Intake Form

Program Overview

Eligibility

Therapy Commitment

Additional Services

Contact

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