Early Intervention Initial Intake Form
Child's Name
*
First Name
Middle Name
Last Name
I have been informed of my right to view my child’s log notes
I have been informed of the confidentiality regulations and understand how my child’s records will be stored and transported.
My child has allergies: (Pick One)
*
Please Select
Yes*
No
If "yes" please complete "Children With Allergies Intake Form"
I filled out the allergies form and discussed an emergency plan with my therapist(s).
I have discussed the IFSP with the team and understand I may change it at any time upon my request.
I have filled out the appropriate consent forms necessary with regards to evaluation, release of medical information, and transfer of records.
I have been informed of the child illness/make-up session policy and procedure.
Signature
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: