Intake Form
Date
/
Month
/
Day
Year
Date
CLIENT INFORMATION
Client's Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Grade
*
Please Select
Pre-School
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
N/A
Gender
*
Primary Language
*
School AND Therapy Centers the Client Attends
*
CONTACT INFORMATION
Parent Name(s) or Emergency Contact
*
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Preferred Contact Method
*
Call
Text
Email
Address
*
Address
Street Address Line 2
City
State
Zip
AVAILABILITY INFORMATION
How often do you wish to receive services?
*
1 day per week
2 days per week
3 days per week
4 days per week
Other
What days work best for services?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What times work best for services?
*
5pm - 6pm
6pm - 7pm
7pm - 8pm
Weekend: 9am - 10am
Weekend: 10am - 11am
Weekend: 11am - 12pm
Other
HEALTH & BEHAVIORAL INFORMATION
Insurance Provider
Health History (Diagnosis, Medications, Surgeries, etc.)
What areas of focus are most important to you?
*
Recreational Therapy
Education
Play
Socialization
Does your child suffer from anxiety? In what areas do you see the most heightened anxiety?
*
How does your child do with outsiders/guests coming into your home?
*
How does your child sleep?
*
Sleeps through the night
Wakes up 2-4 times per night
Has a hard time falling asleep
Wakes up very early
Other
What is your child's diet like?
*
Does your child have any allergies?
*
How does your child communicate?
*
Verbally
Nonverbal
Sign language (ASL)
Assistive device
Other
Please share your religious views / standpoints
Are you willing to participate and learn while we work with your child?
*
Yes
No
What technology is used at home? Are there any that are triggers or issues when using technology?
*
What negative behaviors does your child have?
*
Noncompliance
Yelling
Pacing
Hitting
Punching
Kicking
Biting
Elopement
Disrobing
Property Destruction
Other
What are some antecedents (triggers) that are likely to cause negative behaviors?
*
What is a list of rules that your child has in the home? (Please just list basic "must know" rules)
*
Do you have pets? Please list.
Please list name, age, and relationship to client for all members in your home.
*
Does anyone smoke inside the home?
*
Yes
No
Where will we be working while we are in your home? Do you have an area that we could set up and use as a "home base" for sitting/learning purposes?
*
Kitchen
Living Room
Office
Play Area
Basement
Other
Do we have permission to assist your child with toileting?
*
Yes
No
FINAL NOTES
How did you hear about us?
Word of mouth
Social media
Flyer / business card
Church
Other
Please note any other significant information
I give Embrace Your Ability permission to evaluate and provide services for my child.
*
Printed Name
*
Submit
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