Intake form

1
Client's Full Name
First Name
Last Name
2
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Canada
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Birth Date
Month
Day
Year
4
Health Card #
5
Phone Number
Area Code
Phone Number
6
Diagnosis (List all)
7
1st Parent's/Care Giver's Name
First Name
Last Name
8
2nd Parent's/Care Giver's Name
First Name
Last Name
9
Parent's/Care Giver's E-mail
example@example.com
10
Parent's/Care Giver's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Canada
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Preferred Contact Number
Area Code
Phone Number
12
Alternative Contact Number
Area Code
Phone Number
13
Emergency Contact
First Name
Last Name
14
Emergency Contact Phone
Area Code
Phone Number
15
Agency
16
Agency Contact
First Name
Last Name
17
Agency Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Canada
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
18
Agency Tel:
Area Code
Phone Number
19
Agency Fax:
Area Code
Phone Number
20
Family Doctor
First Name
Last Name
21
Tel:
Area Code
Phone Number
22
Is there any dificulty attenting medical appointment
Yes
No
23
Comments
24
Does the individual suffer from seizures
Yes
No
25
What type of seizures?List all
26
Are there warning signs?
27
Date of last seizure:
Month
Day
Year
28
Drug AllergiesList All
29
Food Allergies
30
Insect bites and stings
31
Seasonal (e.g Hay fever)
32
Others:Please Specify
33
Reactions:
34
Carries EpiPen:
Yes
No
35
Medical Issues
36
COVID-19 Vaccine
None
Single Dose
Fully Vaccinated
Fully Vaccinated + Booster
37
Immunizations
38
Contagious Diseases
39
Needs assistance in walking
Yes
No
40
Needs assistance with wheelchair
Yes
No
41
Needs assistance with stairs
Yes
No
42
Other - Please give details
43
Assistive Devices / Special Devices
44
Any Problems taking medication?
Yes
No
45
Please Specify
46
Check the most appropriate mode(s) of communication
Verbal
Sign Language
PCS
Gestural
47
Please rate on the scale provided
0 - Never
1 - Sometimes
2 - Always
Communicate single words
Communicate phrases
Communicate sentences
Spontaneous communication
Ask questions
Echolalic
Perseverate
Communicate single words
Communicate phrases
Communicate sentences
Spontaneous communication
Ask questions
Echolalic
Perseverate
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
1 of 7
48
Please rate on the scale provided
0 - Never
1 - Sometimes
2 - Always
Come when called by name
Answer questions
Stop activity in response to NO or STOP
Follow simple instructions
Follow complex instructions
Responds to written direction
Responds to sign language
Responds to PCS
Come when called by name
Answer questions
Stop activity in response to NO or STOP
Follow simple instructions
Follow complex instructions
Responds to written direction
Responds to sign language
Responds to PCS
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
0 - Never
1 - Sometimes
2 - Always
1 of 8
49
How does the person react when communication is unsuccessful or not understood?
50
Rate using the following scale
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
Resistant to change
Non-compliant
Bizarre behaviour/self-stimulation
Attention seeking
Hyperactive
Crying/whining
Temper tantrums
*Self-injurious
*Aggressive to others
Destructive to own/other’s property
Sexual inappropriateness
Profane language
Resistant to change
Non-compliant
Bizarre behaviour/self-stimulation
Attention seeking
Hyperactive
Crying/whining
Temper tantrums
*Self-injurious
*Aggressive to others
Destructive to own/other’s property
Sexual inappropriateness
Profane language
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
0 - No
1 - Less than once a week
2 - Less than once a day
3 - More than once a day
1 of 12
51
* Please describe person’s aggressive and self-injurious behaviors:
52
Describe the person’s behaviour when he/she: Cannot be understood
53
Describe the person’s behaviour when he/she: Is denied a request
54
Describe the person’s behaviour when he/she: Is in a new environment
55
Describe the person’s behaviour when he/she: Is in a noisy environment
56
Please list all antecedents to behavioural problems
57
Describe methods of dealing with inappropriate behaviour.
58
Toileting
Yes
No
Independent and spontaneous
Independent on request
Needs physical assistance
Wears diapers during the day
Wears diapers during the night
Independent and spontaneous
Independent on request
Needs physical assistance
Wears diapers during the day
Wears diapers during the night
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1 of 5
59
Other - Please specify
60
Dressing
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
Dressing self
Undressing self
Fastening buttons / zippers
Tie / Velcro – shoes
Chooses clothes
Dressing self
Undressing self
Fastening buttons / zippers
Tie / Velcro – shoes
Chooses clothes
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
1 of 5
61
Hygiene
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
Showers
Shampoo / rinse hair
Shaves
Feminine hygiene
Brushes teeth
Applies deodorant
Showers
Shampoo / rinse hair
Shaves
Feminine hygiene
Brushes teeth
Applies deodorant
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
1 of 6
62
Eating
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
Uses cup / glass
Uses utensils
Cuts food
Uses cup / glass
Uses utensils
Cuts food
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
0 – Independent
1 – Requires some assistance / prompting
2 – Requires hand-over-hand or someone to complete
3 – Requires total assistance
1 of 3
63
Others - Please specify
64
Describe food preferences, dislikes and special dietary requirements.
65
Are there any sleep related problems?
Yes
No
66
Comments
67
To the best of my knowledge, all medical problems, or conditions requiring ongoing medical supervision or care, have been fully noted. I give permission for this health information to be shared with the appropriate camp staff and outside medical personnel as necessary. If the parent or guardian cannot be reached, permission is, hereby, given to the camp staff to contact the camper’s family physician/specialist. (Please inform your physician/specialist that you have given this authorization).* This field is required.I, hereby, certify that all information completed in this form is accurate and up to date.
Agree
68
Signature
69
Relationship to Client
70
* This field is required.
71
Tags
Todo
In Progress
Done
Should be Empty: