Intake Form
Please complete this form in its entirety. Once completed, you will be contacted to schedule an intake.
Participant's Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Participant's Diagnosis
*
Participant's Current Placement (i.e. name of school or program)
*
Participant's Teacher/BCBA contact information (email, phone, etc.)
*
What kind of support does the participant typically need in school or program? (e.g. 1:1, 1:2, in class support, pull out services, etc.)
Please upload a copy of your child's current IEP or ISP.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Accommodation Requests
*
Wheelchair
1:1
Other
None
Please explain any of the above request (if none, type "none"):
*
Please describe the participants means of communication
*
Can be understood by others
Can only be understood by familiar listeners
Uses communication board/device
Gestures
Non-Verbal
Other
Please include any information we should know about the participant. Include notes about behaviors at home, behaviors at school, ability to transition, ability to stay with a group, etc.
*
Please note which of the following medical information the participant experiences:
*
Allergies (food, environmental, etc.)
Diabetes
Seizures
None
Other
Please elaborate on your answer to the question above (if none, type "none").
*
Does the participant need assistance eating/drinking?
*
Yes
No
Can the participant care for his/her toileting needs?
*
Yes
No
Intakes last approximately 30 minutes. You and your child should attend. Please provide days, dates, and times that you are generally available to come in for an intake.
*
Signature
*
I agree the the information provided above is accurate to the best of my knowledge.
Name
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: