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:

How long has the child engaged in each of the behaviors listed above?

What is the severity of each of the behaviors listed above?

Level 1: does not result in visible damage to child, others, or environment. Example: hand mouthing that does not result in broken skin or infection; aggression in the form of open hand hitting that does not cause bruising. | Level 2: might result in visible damage to child, others, or environment. Example: self-injury in the form of headbanging that might result in swelling; aggression in the form of biting that might break the skin | Level 3: often results in visible damage to child, others, or environment Example: self-injury in the form of head hitting that often results in bruising and swelling; aggression in the form of closed fist punches that often results in bruising and possibly concussion

Have the child’s behaviors ever necessitated the use of physical or mechanical restraints (e.g., arm splints)?

Yes
No

If yes, please describe the type of restraint and how often it has been required:

Does the child’s behavior regularly require that either others around them or the child wear protective gear such as arm guards, chest pads, helmets, etc.?

Yes
No

If yes, please describe gear worn:

How many adults are usually required to manage the child’s behavior when they are at their most escalated?

Has a functional analysis ever been conducted on one or more of the child’s behaviors?

Yes
No

If so, what were the results?

What are the common situations in which the child engages in each of the behaviors listed above?

Example: Child engages in aggression when denied access to preferred items; child engages property destruction in the form of overturning potted plants when presented with instructions

How tall is the child?

Approximately how much does the child weigh?

What medications does the child currently receive?

Please list medication names and dosages.

Have any medications been tried and discontinued in the past?

If yes, please list medication names and dosages.

Has the child been suspended or expelled from prior school placements?

Yes
No

If yes, please explain:

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 *

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Name of Person Requesting Intake *

First

Last

Date / Time

REED Intensive Behavior Services (RIBS) Intake Form

Client Information

Parent/Guardian Information

Current Placement