NEW Early Childhood Intake

Early Childhood Intake
Student's Name

First NameMiddle NameLast Name
STN
D.O.B.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is the student currently receiving First Steps services?
Was the student older than 5 years of age on August 1st of current year?

Student Information
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

INTAKE INFORMATION
Date of Intake

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Person Giving Intake Information to School
Referral Source (Agency and/or Person's Name)
Referral Agency's Phone Number
Format: (000) 000-0000.
Date of Contact

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Referral
Comments/Follow Up

Questions for Parents
What percentage of your child's language do you understand?
Please enter 2 digits: example 00, 05 etc
What percentage of your child's language does an unfamiliar listener understand?
Please enter 2 digits: example 00, 05 etc
How does your child get their needs met?
Developmental Checklist
Age Category

2.5 to 2.11
DIRECTIONS:

Please Checkmark all skills the child CANNOT do independently
Gross and Fine Motor 2.5 to 2.11

Person Completing Intake
Your Name

First NameLast Name
Your Email Address
Email Address

You are unable to submit this app. Please contact your school psych (or SLP if speech only).

This child is currently too young to be evaluated by the school corporation. The evaluation process can begin when the child is within a few months of his/her 3rd birthday.
Should be Empty: