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RIBS Intake Form
jayala0612
2022-05-17T20:01:05+00:00
REED Intensive Behavior Services (RIBS) Intake Form
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Client Information
Client's Name
*
First
Last
Client's Gender
*
Male
Female
Decline to State
Different Identity (please specify)
Gender Identity
Client's Date of Birth
*
Primary Diagnosis
*
Presenting Challenging Behavior(s) (Check all that apply*)
*
Self-injury
Aggression
Property Destruction
Disruptive Behavior
Elopement
Stereotypy
Ritualistic Behavior
Other
*To select multiple options, hold the Control button (or Command on Mac) on your keyboard while clicking.
Describe Other Behaviors:
Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Phone
*
Email
*
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Nevada
New Hampshire
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardian Name
*
First
Last
Phone
Email
*
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Current Placement
Name of Current Placement
*
Child Study Team Contact
*
First
Last
Phone
Email
*
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I am submitting the following documentation:
Current IEP (Client is under 21 years of age)
File Upload
*
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Name of Person Requesting Intake
*
First
Last
Date / Time
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