Intake Report (Assessment)


Directions:  For this course you will select a new (real or hypothetical) client with whom to
complete the intake and program development process.  You will be learning about practicing
components of the process throughout the course and receiving feedback along the way.  You will be
asked to complete this assessment throughout the course, as you learn more about each topic area.
When completing this assessment you are welcome to use components that you created on prior
assessments as well as materials that have been provided to you in the class. However, please do
not seek outside assistance, collaborate with other students, or use resources from the internet.


Initial Report Components

A certain number of specific components are expected in each of these areas.  Do your best to
complete each component.


(Please protect client information by using pseudonyms throughout.)


List Identifying Information (12 components):

Feel free to skip this section if you are unsure what goes here and/or copy and paste from your
previous work in this course.










Describe Referral Information (3 components):









Description of the Indirect Assessment Process (3 components):









Background Information (13 components):






Preferences (3 components):






Challenging Behavior Report Components

A certain number of specific components are expected in each of these areas.  Do your best to
complete each component.


(Please protect client information by using pseudonyms throughout.)


Functional Assessment for Behavior One (14 components):










Functional Assessment for Behavior Two (14 components):





Intervention/Program Planning Report Components

A certain number of specific components are expected in each of these areas.  Do your best to
complete each component.


(Please protect client information by using pseudonyms throughout.)


Intervention Strategies for Behavior One (11 components):




Intervention Strategies for Behavior Two (11 components):





Additional Skill Acquisition Targets  (8 components):






Caregiver Support Report Components

A certain number of specific components are expected in each of these areas.  Do your best to
complete each component.


(Please protect client information by using pseudonyms throughout.)


Basic Caregiver Training Plan (5 components):





Baseline Data (2 components):






Caregiver Support Goals (13 components):