During a diagnostic evaluation, a standard intake is meant to collect and organize information about a client prior to treatment. It is used as a platform for the clinician and client to clearly communicate their concerns. The information gathered during the intake is used to help formulate diagnoses and create individualized treatment plans.
In the field of pediatrics, parents and guardians are essential in the treatment process. Diagnostic evaluation intake forms are used to gather as much relevant information about a client as possible prior to treatment. It is important to listen to what they have to say because parents and guardians know the child best out of anyone.
Areas of an intake form include:
- Guardian information
- Pediatrician information
- Emergency contacts
- Family history
- Purpose of the evaluation
- Medical history
- Developmental history
- Education history
- Language skills
- Social skills
- Behavioral/social history
Guardian Information
This area of the intake form gathers contact information in order to ensure clear communication between the clinician and guardian(s). Contact information includes the name(s) of the guardian(s), e-mail, address, and phone number as well as their preferred method of contact.
Pediatrician Information
Basic information about the child’s pediatrician is kept on file including their name, address, and phone number.
Emergency Contacts
The safety of the child is of utmost priority, so emergency contact information is kept on file. This information includes an emergency contact’s name and phone number.
Family History
Gathering information about family history helps clinicians get a full picture of the child. Helpful information to know about family history includes the number of siblings, the child’s primary language, and history of conditions in the immediate and extended family.
Purpose of Evaluation
This area provides insight into why an evaluation is desired. This allows current concerns to be stated as well as provide a brief history of the child. This history includes any current or past diagnoses the child has and if the child has received other services.
Medical History
It is essential to get a detailed medical history of a child prior to intervention in order to develop an effective and safe treatment plan. A brief overview of the medical history includes birth history, medications, surgeries, hospitalizations, and any hearing or vision problems the child might have.
Developmental History
A child’s developmental history is essential in creating an effective treatment plan. This history includes language milestones, motor milestones, gross and fine motor abilities, feeding or eating concerns, and development concerns.
Education History
If the child is old enough to have attended school, basic information on their education is collected. This includes schools attended, pre-academic concerns, learning concerns, and 504 Plans/IEPs.
Language Skills
There are many components to language. These skills include eye contact, non-verbal communication, responsiveness to directions, repetitive behaviors, and conversational abilities.
Social Skills
Social skills include a variety of things, but a broad overview includes how a child plays with their peers and how they engage in imaginative and creative play.
Behavioral/Social History
A child’s behavioral/social history includes current behavior concerns, triggers for challenging behaviors, and disciplines/interventions used with challenging behaviors.
