Follow the steps to successfully complete the intake form.

1. Press the ‘Get Form’ button to access the ABA Chicago Intake Form - Wheels Of Wellness. This will open the form where you can begin providing the required information.
2. Complete the 'Child Information' section. Fill in relevant details such as the child's last name, first name, home phone number, address, city, state, zip code, and county. Additionally, indicate how you were referred to Wheels Of Wellness, today’s date, the child’s age, and date of birth.
3. In the 'Diagnosis' section, provide the primary diagnosis, any secondary diagnoses, and other conditions as necessary. Include the respective dates of diagnosis.
4. Fill out the 'Legal Guardian Information.' Enter the full name, address (if different from the child), relationship to the child, and contact information for the legal guardian. Repeat this for any additional legal guardians.
5. List the applicant's siblings. For each sibling, provide their name, age, and gender as requested.
6. Move on to the 'Present School/Placement' section. Fill in the name of the school, its address, phone number, teacher’s name, years attended, and placement details. Indicate if the child has an IEP or a 504 plan.
7. In the 'Medical Information' section, answer whether your child is on medication for behavioral issues, list the primary physician and their phone number, and detail any specialists involved in the child's care. Note any special diets or medical conditions that should be considered.
8. Complete the 'History of Treatment' section. Provide information about previous behavioral or other provider treatments, including the provider/agency name, dates of service, frequency of consultations, and methods of treatment used. Describe the services and results achieved.
9. List any supportive services the child is currently receiving, both in-school and out of school. This may include services like speech therapy, occupational therapy, and others, along with their respective locations and frequency.
10. Identify the top three behaviors of concern. Describe each behavior in detail, including frequency, duration, and location of occurrence.
11. Finally, articulate the main goal for services, current communication skills, social skills level, child's strengths, and any additional information pertinent to the child that may assist in delivering effective services.
12. Once all sections are filled out, save your changes, and you may choose to download, print, or share the completed form as necessary.

Complete your ABA Chicago Intake Form - Wheels Of Wellness online now for support services tailored to your child's needs.