Intake Form

Thank you for contacting the Bluewater Behavioral Services! The following Intake Documents Packet is needed to begin the intake process. If at any time you have questions or concerns about these documents, please contact our intake department Amy@BluewaterBehavioral.com at (850)-842-9743.

Intake Process Steps:
- Contact Bluewater Behavioral Services
- Collection of health insurance information (from initial application for services)
- Return insurance benefit information to parents once obtained (typically 1-3 days)
- Complete this Intake Documents packet
- Intake assessment meeting with a BCBA scheduled and completed (typically 2 hours)
- Plan of care submitted to insurance company by BCBA, for authorization of ongoing services
- Insurance company reviews, and approves plan of care (Typically 1-7 days) Finalize scheduling details
- Services can begin!
Please note, that these steps may vary depending on your insurance, or method of payment (private pay, Tricare, Medicaid, etc.)

You are welcome to fill out this form as a word document and return it via email to: Amy@BluewaterBehavioral.com or Info@BluewaterBehavioral.com

If you are unable to insert a .JPEG file of your signature on the pages requiring a signature, we are happy to print this document for you, for you to sign in person at your child’s initial assessment appointment.

You are also welcome to print and fill this form out by hand, and scan/email, or mail the completed form to:

Bluewater Behavioral Services
4451 Parkwood Square
Niceville, FL 32578
GENERAL CLIENT INFORMATION
Client Name:*

First NameLast Name
Client DOB:

MonthDayYear
Client Gender:

MaleFemale
Contact Name:
Relationship to Client:
Contact Home Phone Number:
Contact Cell Phone Number:
Contact’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Client Address (if different than contact’s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
MEDICAL INFORMATION
Diagnosis:
Diagnosing Physician:
Date of Diagnosis:
Medication:
Dose/Frequency:
Purpose:
Allergies Please list any allergens, the child's reaction to the allergen, and whether or not there are any emergency procedures (call 911, epipen, etc.) followed if he/she were to come into contact with this allergen.
Medical Devices, Please list any medical devices your childuses on a daily basis (Orthotic braces, wheelchair, crutches, etc.)
MEDICAL INFORMATION
Please explain any concerns with the following milestones, when the client was an infant/toddler. Complications during birth:
Please explain any concerns with the following milestones, when the client was an infant/toddler. Complications during birth:
Language/communication milestones (pointing, babbling, talking):

PointingBabblingTalking
Motor Skills:
Walking/Crawling:
Social/Emotional (difficult to soothe, eye contact, peerinteractions):
Was there any regression of milestones after they had beenachieved?
PARENT QUESTIONNAIRE: PLAY AND SOCIALIZATION
Please list 3-5 items that your child enjoys.
For how long does your child remain engaged withthese items?

Less than 1 minute3-5 minutes10+ minutesFor as long as allowed
Does your child play with these toys/items as intended? (pushing acar down a ramp, coloring with crayons, dressing dolls, etc)

YesNoSometimes
Does your child willingly share toys with others?

YesNoSometimes
Does your child approach others in a play setting?

YesNoSometimes
Please give examples of what their peer interactions look like, if applicable.
Does your child imitate motor actions if prompted?

YesNoSometimes
Parent Questionnaire: Communication
How does your child request toys, snacks, and other preferreditems? Please check all that apply.

Spoken LanguagePECS/PicturesElectronic devicePointingGesturesSignsOther vocalizationsOther
My child uses (Check all that are applicable):

Single words/signs2-3 word requestsFull sentencesNounsVerbsAdjectivesPronounsRepositionsAdverbs
Will your child repeat words/phrases (from a show, a song, an adult, etc?)

Yes, spontaneouslyYes, when askedNoYes, but out of context/repetitively
Does your child respond by looking at the speaker when his/hername is called?

YesYes, but does not make eye contactNo
Does your child comply with 1-step instructions from adults?

YesYes, 2-3 step instructionsyes, only familiar adultsNo/inconsistently
Please list an example of instructions your child will follow without prompting.
Does your child select from pictures/items on a table when asked, “where is the” Please check any that apply:

Familiar peopleCommon itemsBody partsClothingActions (-ing endings)Adjectives (Shapes, colors)
Does your child label items in the environment? Please check any that apply:

Familiar peopleCommon itemsBody partsClothingActions (-ing endings)Adjectives (Shapes, colors)
Does your child request by combining parts of speech? (e.g., redball, mama come, play show)

YesYes, with promptingNo
Does your child fill in words from songs or familiar phrases? Ifso, please list some examples.Please list an example of instructions your child will follow without prompting.
Does your child answer questions about themselves? (name, age,parents' name, etc.) If so, please list some examples.
Does your child answer questionsabout events that have happened earlier in the day? (what did you eat forbreakfast? What did you do at school? Who did you see yesterday?) If so, pleaselist some examples.
Parent Questionnaire: Self-Help Skills
Please describe any concerns in the following areas:
Feeding/Meal times:
Toileting:
Grooming:
Dressing:
Sleeping:
Community Safety:
Parent Questionnaire: Maladaptive Behavior
Does your child engage in any problem behavior that impedes dailyactivities, everyday life, or social interactions? If so, please describe whatthese behaviors look like:
Tantrums (check if applicable)

FloppingCryingScreamingYellingElopement
How often do tantrums occur?

DailyWeeklyOnce per month or less
How long do they last?

less than 1 minute3-5 minutes10+ minutes30+ minutes
How long do they last?

less than 1 minute3-5 minutes10+ minutes30+ minutes
What typically causes tantrums, and what typically ends the tantrum?
Aggression (check if applicable)

HittingKickingPushingScratchingBitingProperty Destruction
How often does aggression occur?

DailyWeeklyOnce per month or less
Do any of the above behaviors leave bruises or marks on another person?

YesNoSometimes
Who is aggression typically directed towards?
What typically causes aggression, and what typically ends aggression?
Self-injury (check if applicable)

PinchingHittingScratchingBitingHead-bangingOther
How often does self-injury occur?

DailyWeeklyOnce per month or less
How long do instances last?

less than 1 minute3-5 minutes10+ minutes30+ minutes
What typically causes self-injury, and what typically ends send-injury?
Stereotypy (check if applicable)

hand/limb flappingodd or repetitive vocalizationsOther:
How often does stereotypy occur?

DailyWeeklyOnce per month or less
How long do instances last?

less than 1 minute3-5 minutes10+ minutes30+ minutes
What typically causes stereotypy, and what typically ends it?
Consent to Release Information to Primary Care Provider

Please review the Release of Information form below and provide consent to Bluewater Behavioral Services (BBS) to send records to the primary care Provider (PCP) overseeing your child’s care. In the event that there is a change in the child’s care, please contact BBS and update the information as appropriate. Thank you!

Communication between behavioral health providers and your child’s primary care physician is important to help ensure that your child receives comprehensive and quality health care. This information may include, but may not be limited to, plans of care, progress notes, assessments and behavior reduction plans. This consent shall not expire while receiving services at Bluewater Behavioral Services, unless revoked in writing.
I
, parent/guardian of
for the purpose of coordinating care, authorize Bluewater Behavioral Services (BBS), to release information indicated in the consent portion of this form to:
Primary Care Provider Name:
Primary Care Provider Phone Number:
Primary Care Provider Fax:
Primary Care Provider Address:
I, the undersigned, understand that I may revoke this consent at any time, in writing, and that this consent will remain on file for the duration of my care at BBS. I have read and understood the above information and give my consent:
PLEASE CHECK ONE OF THE FOLLOWING:

To release any applicable client information to my child's PCPI do not give my consent to releasing any information to my child's PCP
Parent/Guardian Full Name:
Date:
Signature

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