INTAKE FORM
(Please print this page, fill out, and send to the address listed at the bottom or download the pdf.)

NAME OF CLIENT:

AGE: DOB: DATE:

NAMES OF IMMEDIATE FAMILY MEMBERS:

MARITAL STATUS (if child, status of parents): (circle) SINGLE, MARRIED, SEPARATED, DIVORCED

EMAIL (for confirmation that we received this form):

ADDRESS: Street:

City: State: Zip code:

PHONE: (H) (W) (CELL)

NAME OF SCHOOL: GRADE (or equivilant):

WHAT KIND OF CLASS IS STUDENT IN: (For children and adolescents only. Circle all that apply:)

1. REGULAR EDUCATION/FULLY MAINSTREAMED
2. REGULAR ED WITH SUPPORTS (AIDE, 504 PLAN, OTHER: )
3. RESOURCE ROOM FOR SUBJECTS:
4. SELF-CONTAINED CLASS
5. SPECIAL ED SCHOOL
6. DISCRETE TRIAL OR ABA HOME PROGRAM
7. OTHER:

1. CURRENTLY EMPLOYED AS A
2. LOOKING FOR EMPLOYMENT AS A
3. INVOLVED WITH THE OFFICE OF VOCATIONAL REHABILITATION TO FIND EMPLOYMENT
4. WORKING IN A SHELTERED WORKSHOP
5. GOING TO COLLEGE AT
6. GETTING SPECIFIC VOCATIONAL TRAINING AT

ANY FORMAL DIAGNOSES:

ANY MEDICATIONS (dose and frequency):

SPECIFIC CONCERNS: (State your specific concerns and those expressed by teachers and others.)

ANY HISTORY OF SUICIDAL THOUGHTS OR GESTURES (words or actions):

ANY AGGRESSIVE BEHAVIORS (e.g., hitting, biting, or verbal threats):

POSSIBLE SERVICES DESIRED: Circle desired services:

AVAILABILITY FOR APPOINTMENT TIMES: (the more times you list, the easier it will be to make an appointment)

REFERRAL SOURCE:

Mail all forms to:

Jed Baker, Ph.D.
29 Collinwood Rd.
Maplewood, NJ 07040