Inhome Aba Program Intake Packet Page 10
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27Behavior Matters, LLC
Teaching Skills for Success
(253) 686-6958;
DEVELOPMENTAL H ISTORY:
1. P lease i ndicate t he a ge a t w hich y our c hild d id t he f ollowing:
Rolled o ver c onsistently
Said t wo-‐three w ord p hrases
Sat u p u nsupported
Used S entences r egularly
Stood
Toilet t rained d uring t he d ay
Crawled
Dry t hrough t he n ight ( 6+ m onths)
Walked U nassisted
Dressed S elf
st
Said 1
W ord I ntelligible t o s trangers
2. Please i ndicate i f y our c hild i s e xperiencing a ny o f t he f ollowing:
Problems w ith e ating ____________
Isolated s ocially f rom p eers _ ___________
Problems m aking f riends
____________
Problems k eeping f riends
____________
Problems g etting t o s leep
____________
Problems c ontrolling t emper
____________
Nightmares
____________
Bed W etting / S oiling
____________
Problems w ith a uthority
____________
Anxiety
____________
Unmotivated
____________
School c oncentration d ifficulties
____________
Grades d ropping o r c onsistently l ow
____________
Sadness o r D epression
____________
10
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