Appendix K: Butterfly

Effects, LLC.
Application Form & Parent Questionnaire
Contact Information
Client Name: Daniel Roque Age: 4 years and 10 months
DOB: 08/27/2015 Grade: Pre-K 2020-2021

Date Form Completed: 6/4/2020 Gender: □ Male □ Female

Languages Spoken in the home: English and Spanish

Person Completing this form: Mother
Mother’s (or Parent 1) Name: Victoria Roque

Address: 19161 NW 57th CT, Hialeah FL, 33015

Email Address: Vicky9271@yahoo.com
Home Telephone: (786)488-3304 Work Telephone:

Father’s (or Parent 2) Name:

Address:

Email Address:

Home Telephone: Work Telephone:

□ Married □ N e v e r Married
□ Divorced/Separated □ Widowed
□ Other custody arrangement:
Parents Marital Status / Family
Composition: Please describe family composition including people living in
the home (e.g., siblings & ages):

Mom and 12 year old brother

If never married/separated/divorced,
is there joint custody? □ Yes □ No
Contact with non-custodial parent or custody arrangement if
Custody Arrangements: any: No contact

DCF involvement: □ Yes □ No

Case worker name:
Contact information:

Name: Victoria Roque (Mother)

Emergency Contact: Relationship to the child:
Phone Number: 786-4883304
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Diagnostic Information: Diagnosing Clinician: Elza Vasconcellos
 Practice Name:
Date of Assessment:

DSM-5 / ICD-10 Diagnostic Code:

□ ASD DSM-5 299.00
□ ICD-10 F84
□ Secondary/Other:

Primary Care Physician (PCP) and Insurance Information

PCP: Ann Margaret Villar PCP Address: Chapel trail
PCP Phone: (954) 430-9300 PCP Fax:
Insurance Provider: Aetna better health Insurance ID:
Group Number: Membership Number:

Reason for Referral

Why are you pursuing home based Child’s need for behavior improvment and recent
ABA services?
diagnosis of ASD.

Who referred your child to BE?

Self
What are your expectations from
Child’s behavior improvment
ABA treatment and BE Services?

Are there cultural or spiritual Describe:

believes that may impact treatment
□ Yes □X No
Described any potential barriers that Describe:
may impact treatment?
□ Yes □ No
What is your child’s availability for Mon. Tue. Wed. Thu. Fri.
treatment: 8:00-11:00am □ □ □ □ □
Please check all available times for treatment.
11:30-1:30pm □ □ □ □ □
1:00-3:00pm □ □ □ □ □
3:00-6:30pm □ □ □ □ □

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Developmental History

Yes No Comments:
Prenatal Complications: X Late-preterm
Postnatal Concerns: X Nicu
Exposure to drugs or toxins in
utero: X
Motor Development: (e.g., met
milestones such as siting by 6
month, crawling by 8 months and
walking by 12 months) X
Problems with mobility or
coordination:
(e.g., ride a bike, catch a ball) X
Language Development:
(e.g., single words by 12 months, X
two word phrases by 24 moths,
sentences by 36 months)
Does your child have difficulty
following directions? X
Does your child have articulation
or intelligibility issues? X
Does your child have difficulty
within the social domain? X
Does your child have difficulty
with play or leisure skills? X
Did your child struggled with early
academic skills (e.g., learning
colors, the alphabet, counting) X Refuses to learn how to write
Is your child toilet trained? If so at
Potty trained at 3 1/2 Still uses pampers overnight
what age? X
Is your child trained through the
night? X

Medical History
Yes No Comments:
Any diagnosed genetic or medical
conditions? X
Problems with vision? X Severe myopia
Concerns about hearing? X Date of hearing test:
History of chronic ear infections? X
Tubes? Date of surgery:
X

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 Yes No Comments:
Heart defects? X
History of serious illness? X
Hospitalizations? X Observation for seizure like episode
Surgeries? X
Serious injury (i.e., broken bones)? X
Seizures, convulsions, staring
spells? X
Head injury or loss of
consciousness? X
Allergies? X SSRI
Reflux, constipation, or other
gastrointestinal issues? X
Problems with feeding (i.e.,
chewing, swallowing, history of
chocking) or restricted diet? X Picky eater
Problems with sleep (i.e., bed
routine, sleep onset, night waking,
night terrors?) X Difficult for child to go to bed
History of sexual abuse: Victim □ Yes □ No
Perpetrator □ Yes □ No
Specify:
X
History of physical abuse or
neglect: X
Document past and present use of Prescription/ medications □ Yes □ No
alcohol and/or illicit drugs: Nicotine □ Yes □ No
Alcohol □ Yes □ No
X Other Substance □ Yes □ No
History of Suicidal Behavior:

Please list current medications: Name of Medication:

Prescribed for:
Prescribing Doctor:

Name of Medication:
Prescribed for:
Prescribing Doctor:

Please list all past medications:

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Family Medical History
Yes No Comments:
Any history of learning challenges
(i.e., reading, writing, math) within
the family?
Any family of history of
developmental delays (i.e., Autism,
intellectual disability)?
Any family history of problems
with the regulation of attention or
behavior?
Any neurological or genetic
conditions within the extended
family?
Any history of history of mood
disorders (i.e., bipolar) or
psychiatric conditions (i.e., anxiety,
schizophrenia)?

Previous Evaluations and Treatments (please provide copies)

DATE AGE Professional, Discipline, & Agency

Early Intervention Evaluation
Diagnostic Evaluation
Psychological/
Neuropsychological Evaluation
Speech & Language
Occupational Therapy
Physical Therapy
School Based Testing
Other specialists: Neurologists,
Developmental Pediatrics,
Psychiatrist
Specialty Services
ABA treatment history
Functional Behavior Assessment
(FBA) / Behavior Management
Support Plan (BSP)

Please described your child’s

current services including school
and all private therapies

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 DATE AGE Professional, Discipline, & Agency
Is your child on an IEP/504 plan? Describe services:

Community resources (support

groups, social services, school-
based services) being utilized:

Current Functioning & Behavior Concerns

Language & Communication Domain

Primary mode of communication: □ signs/gestures □ single words
□ picture supports (PECS) □ phrase speech
□ device/Ipad □ fluent language
Please describe your child’s
language and communication
strengths:

Please describe your concerns

relative to speech, language,
and communication:

Socialization Domain
Please describe your child’s
strengths within the interpersonal
and socialization domain:

Describe your concerns in the

socialization domain:

Play/Leisure Skills
Please describe current play
preferences or interests in the
leisure domain:

Yes No Comments
Does your child play
independently?
Does your child play interactively
with other children or adults?

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Does your child engage in pretend
or imaginary play?
Does your child take turns with
games?
Behavior Concerns
Yes No Comments
Does your child display Hits □ Kicks □ Bites □ Hair Pulls □
aggression? Other □
Towards Adults □ Towards Peers □
Does your child engaged in Self- Head bangs □ Skin picks □ Self Bite □
injury (e.g., harmful behaviors)? Has cause tissue damage? Yes □ No □
Specify:
Does your child engage in tantrum Frequency:
behavior? Duration of tantrums:
Describe a tantrum:

Does your child engage in

noncompliant behavior?
Atypical behaviors Motor stereotypy Yes □ No □
Vocal stereotypy Yes □ No □
Repetitive Behaviors Yes □ No □
Restricted Interests Yes □ No □

Describe:

Bolting Wanders from room Yes □ No □

Has left house/school Yes □ No □
Has wandered from residence during
overnight hours? Yes □ No □
Frequency:
Date of last wandering:
Pica (ingests inedible objects) Frequency:
Objects ingested:
Date of last ingestion:
Transportation related issues Removes seal belt Yes □ No □
Wears safety harness Yes □ No □
Has attempted to exit stationary vehicle
Yes □ No □
Attempts to interfere with driver Yes □ No □
Frequency:
Date of last transportation issue: