RIBS Intake Form

Client Information

Client's Name *

First

Last

Client's Gender *

Gender Identity

Client's Date of Birth *

Primary Diagnosis *

Presenting Challenging Behavior(s) (Check all that apply*) *

*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

State

Zip Code

Parent/Guardian Name *

First

Last

Phone

Email *

Address

Address Line 1

Address Line 2

City

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

State

Zip Code

I am submitting the following documentation:

Current IEP (Client is under 21 years of age)

File Upload *

Click or drag files to this area to upload. You can upload up to 5 files.

Name of Person Requesting Intake *

First

Last

Date / Time

REED Intensive Behavior Services (RIBS) Intake Form

Client Information

Parent/Guardian Information

Current Placement