Northwest's Child & Aaron's Place Intake Form

Intake Form

Northwest's Child and Aaron's Place
Date

MonthDayYear
Date
Name of Client

First NameLast Name
Age of Client
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Optional) Photo Upload

You are welcome to upload a photo of your child with this form. This helps our team put a face to the name when communicating with parents, caregivers, and teachers—especially as we receive many intakes and some students are placed on a waitlist. Having a photo allows us to better remember students we've already met or observed. Photos will be used only for internal reference and kept securely.
Cancelof
Diagnosis
School
Teachers Name
Teachers Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Teachers E-mail Address
example@example.com
Name of Parent/Guardian

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Name of Parent(s)/Guardian

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?
How does your child communicate best: (please check all that apply)

VerbalNon-VerbalCommuncates primarily with gesturesCommunicates with communication deviceUses sign languageUses PEC systemOther
Preferred language: (spoken and/or written)
How does your child typically move through their environment?: (please check all that apply)

Walks independentlyUses a manual wheelchairUses a power wheelchairUses a stroller chair and is able to transfer outUses a walkerAmbulatory but needs assistance (Needs to hold a hand or an arm to safely transport)Other
What does your child require for safe transportation in a vehicle? (please check all that apply)

Sits in a standard seat with seatbeltRequires a car seat or booster seatTransfers from wheelchair into carseatTransfers from wheelchair into a standard seatRemains in wheelchair during transport (secured with tie-downs)Other

Please check in Box for each task that best applies

Rows	Full Assistance	Partial Assistance	Independent
Toileting Care
Skin Care/Bathing
Hand Washing
Lotions/Ointment
Skin Dressing
Oral Care
Walking
Sitting
Transferring
Repositioning
Range of Motion
Meal Preparation
Fluid Intake
Cleanning/Shopping
Laundry
Clean Equipment
Table/Area Clean
Safety Care
Communication of personal needs
Transportation

Does your child use a g-tube for nutrition, water, and or medication administration?

YesNo
What is something that would typically anger client?
How would he/she react to that situation?
What is something that would typically make the client sad or upset?
How would he/she typically react to that situation?
What is something that would typically make the client happy?
How would he/she react to that situation?
How is he/she around animals?
Does he/she ever use restraints at home or school

YesNo
Does your child have an IEP and or a behavior plan in place?

YesNo
If yes, please share details or bring a copy to our intake visit.
Is your child on any medications? (Please list all medications and reason perscribed)
Does your child have any allergies? If yes, please list all, including what reaction looks like (include treatment).
Additional information you would like us to know?
Ideal Start Date
Which Location are you interested in? (Please check all that apply)*

NWC Edmonds (school age)Aaron's Place SeattleAaron's Place GreenlakeAaron's Place ShorelineAaron's Place BothellAaron's Place Kirkland
What type of schedule are you interested in for your child?

Year RoundSummer onlyFull time (5 days per week)Part-time
If you selected part-time, please select all that apply:

Two days per weekThree days per weekFour days per week
*Administrator*
- Admin Use only
- Phone call with parent?
  
  yesno
- Notes from phone call with parent:
- Notes from communication with parent:
- Notes from Communication with Teacher/Para
- Thank you for completing the intake! We look forward to reading more about your son or daughter and will be in touch soon. If you have any follow-up questions, please feel free to email inquiries@northwestschild.org or call 206-526-2493
- Should be Empty:

Intake Form

Admin Use only