Client Behavior Questionnaire

This questionnaire helps us understand your child’s current behaviors, challenges, and strengths. Your detailed responses will assist us in creating an individualized treatment plan that best meets your family’s needs.

Email *

Client's Full Name *

Client Date of Birth *

Parent/Guardian Full Name

Main behaviors of concern

How often do these behaviors occur? *

Multiple times daily

Once daily

A few times per week

Occasionally

When are these behaviors most likely to occur

What triggers these behaviors

Specific people environments or routines involved

What strategies have you tried

Were strategies effective

Rewards or routines at home

Frustration When Communication Unsuccessful?

Yes

No

Sometimes

Short-term goals (next 6 months)

Long-term goals (12 months)

Please Upload Recent Diagnosis Report *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Parent/Guardian Signature *

Clear

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Client Behavior Questionnaire

Share details about the behaviors, routines, and goals that matter most so our BCBAs can prepare for your intake.

Client Behavior Questionnaire