Intake Form

Intake Form
Date

Month Day Year
Date
CLIENT INFORMATION
Client's Name *
Date of Birth *

Month Day Year
Date
Age
Grade *
Gender *
Primary Language *
School AND Therapy Centers the Client Attends *
CONTACT INFORMATION
Parent Name(s) or Emergency Contact *
Email *
example@example.com
Phone *
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. *

Clear
Printed Name *
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Intake Form

CLIENT INFORMATION

CONTACT INFORMATION

AVAILABILITY INFORMATION

HEALTH & BEHAVIORAL INFORMATION

FINAL NOTES