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Beyond the Spectrum Intake Form
Thank you for your interest in our school. We proudly serve individuals ages 5 (as of September 1st, 2018) through 22+, and we look forward to learning more about yours! Once your form is submitted, you will receive a call or email to schedule a tour and assessment at our school. **Please note that admission packets remain on file for 12 months after submission. Thank you!**
Student Name
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
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Month
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Day
Please select a year
2025
2024
2023
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Year
Student's Age
Please Select
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Registering Parent/Caregiver's Name
First Name
Last Name
Parent/Caregiver #2's Name
First Name
Last Name
Intended School Year for Enrollment
Student's Present Grade
Student's Enrolling Grade
Student's Height and Weight
Student's Current School (if applicable)
School Address & Phone
Student Photo
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Student's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver 1 Phone Number
Parent/Caregiver 2 Phone Number
Alternative Phone Number #1
Alternative Phone Number #2
Parent/Caregiver 1 Email
example@example.com
Parent/Caregiver 2 Email
example@example.com
Does your student have an IEP (Individualized Education Plan)?
Yes
No
What is your student's Matrix Score?
251 (Level 1 of Support)
252 (Level 2 of Support)
253 (Level 3 of Support)
254 (Level 4 of Support)
255 (Level 5 of Support)
Not sure
Please attach IEP if you have a digital copy.
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Please attach any other additional documentation you may have (diagnosis reports, psychological evaluations, etc.).
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Funding Information
For assistance with school funding, please contact our Financial Director, Peggy Caruso, at 941-447-8400.
Please select the funding you currently have for your student.
A.A.A. Scholarship
Family Empowerment Scholarship - Unique Abilities (FES-UA)
Private pay
N/A
Intake Questionnaire
At Beyond the Spectrum, we offer three specialized educational programs. Some questions may not be relevant to your child, but please answer those that are applicable to the best of your ability so we can better understand your student's individual circumstances, needs, interests, and goals. Thank you!
How did you hear about Beyond the Spectrum? Briefly describe how you anticipate your experience at BTS might differ from mainstream schooling.
Please select any Developmental/Neurological Diagnoses that apply to your student.
Autism (ASD)
Aspberger's
Down syndrome
Fetal Alcohol Syndrome (FAS)
Seizure Disorder
N/A
Other
Please select any Sensory/Motor Diagnoses that apply to your student.
Apraxia
Cerebral Palsy
Fine Motor Delay
Sensory Integration Disorder
Sensory Processing Disorder
N/A
Other
Please select any Learning-related Diagnoses that apply to your student.
Dyslexia
Dysgraphia
Dyscalculia
N/A
Other
Please select any Behavioral/Mood Diagnoses that apply to your student.
Attention Deficit - Hyperactive (ADD-H)
Attention Deficit - Inattentive (ADD-I)
Attention Deficit - Combined (ADD-H/I)
Anxiety Disorder (Generalized)
Bipolar Disorder
Depression
Obsessive Compulsive Disorder (OCD)
Oppositional Defiance Disorder (ODD)
Post-Traumatic Stress Disorder (PTSD)
Separation Anxiety
Social Anxiety/Phobia
Tourette's Syndrome
N/A
Other
If you selected "other" to any of the above inquiries, please add your response below.
If your student has any of these diagnoses, is he/she aware of them?
Yes
No
If yes, what do you refer to them as / what do you call them?
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Medical Profile
Please identify all medical conditions your child currently has or has had in the past.
Please select any of the following that apply to your student.
Allergies
Asthma
Auto-Immune Disease
Diabetes
Heart Condition
N/A
Other
If you selected "Other," please add your response below.
Please list any food allergies your student has.
Please list any non-food allergies your student has.
If your student has allergies, what are the signs and symptoms of an allergic reaction?
Does your student have an Epi-Pen for severe allergic reactions?
Yes
No
Any other medical conditions or health concerns:
Is your student on a special/limited diet, or does your student have specific feeding needs?
Yes
No
If yes, please explain below.
Please list all medications that your student takes regularly; please include dosage, frequency, and the prescribing physician.
If your student regularly experiences any of the following symptoms, please select them below.
Acid Reflux/Indigestion
Bruises easily
Chronic congestion
Dark undereye circles
Eczema/skin rashes
Frequent constipation
Frequent diarrhea
Frequent ear infections
Headaches
Hyperactivity
Mood swings
Refusal to eat
Seasonal allergies
Sensitive to light
Sensitive to sound
Tires easily
Any additional notes or concerns regarding your student's health:
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Services & Therapies
Please indicate the current services and therapies your student receives.
Please select the services your student receives below:
ABA (Applied Behavioral Analysis Therapy)
Music Therapy
Occupational Therapy
Physical Therapy
Speech/Language Therapy
Other
Please indicate the providers and hours per week for the services you selected:
Any additional notes regarding therapies for your student:
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Academic Profile
To the best of your knowledge, please circle what your child can do independently. Please note that this is not a comprehensive list of all academic skills, but rather a way for us to have an idea of your child's abilities.
Approximate Grade Level for Reading/Writing:
Student's Independent Reading/Writing Skills
Identify letters
Read sentences
Read sight words
Read short books
Read chapter books
Write his/her name
Write complete sentences
N/A
Approximate Grade Level for Mathematics:
Student's Independent Mathematics Skills
Identify Numbers
Count to 10
Count to 100
Basic addition
Basic subtraction
Basic multiplication
Basic division
Do you have a goal for your student to earn any of the following certifications?
Florida ACCESS Standard Diploma
Vocational certification
Not sure
N/A
Other
If "Other," please describe.
Any additional comments regarding your student's academic progress:
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Personality Profile
Please respond to the following with what best applies to your learner
Student's Personality Traits
Active
Affectionate
Aggressive
Analytical
Anxious
Confident
Dependent
Even-tempered
Follower
Impulsive
Independent
Leader
Moody
Non-active
Playful
Quiet
Sensitive
Serious
Shy
Talkative
Describe what you enjoy most about your child.
Any Additional Comments?
Does your student prefer to be alone or with others?
Alone
With others
No preference
Does your student initiate interaction with parents/guardians?
Yes
No
Only if he/she wants something
Does your student initiate interaction with other adults?
Yes
No
Only if he/she wants something
Does your student initiate interaction with siblings?
Yes
No
Only if he/she wants something
Does your student initiate interaction with peers?
Yes
No
Only if he/she wants something
What does your child like to do independently?
What does your child like to do with others?
Other activities, interests, or comments:
Communication & Hearing - Does your student have difficulty with any of the following?
Apraxia
Articulation
Auditory Processing Disorder
Deaf/Hearing Loss
Fluency of Speech
Scripting/Echolalia
Stuttering
Voice Disorder
Other
If you selected "other," please add your response below.
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Please select all that is true for your student:
Has no verbal language
Has limited verbal language
Can answer basic questions
Is conversational
Communicates in full sentences
Is difficult to understand
Uses PECs to communicate
Uses device to communicate
Uses sign language
Points to what he/she wants
Uses gestures
Does not voluntarily speak/must be prompted to speak
Please select the best-fitting answers for your student.
Always
Often
Rarely
Never
Student has difficulty with organization skills.
Student has difficulty with maintaining attention.
Student has difficulty with transitions
Student can get "stuck" on tasks or requests.
Student is flexible/adaptable.
Student can be forgetful.
Student can learn from his/her mistakes.
Student requires assistance to stay on task.
Does your student have a one-on-one aide at school?
Yes, full-time
Yes, part-time
No
Any additional comments regarding your student's executive functioning skills:
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Behavioral Profile
Please respond to the following inquiries to the best of your ability.
Does your student have a current behavior plan at school?
Yes
No
Does your student receive behavior services at home or in a clinic?
Yes
No
Can you, alone, take your student and another sibling/friend of the student into the community without difficulties?
Yes
No
Has your student been asked to leave a program or not come back for a following session?
Yes
No
If yes, please explain:
Has your student displayed any of the following in the past year?
Biting
Damaging property
Eloping/running away
Excessive lying
Head banging
Hitting - closed fist
Hitting - open hand
Kicking
Refusing to do tasks
Scratching
Spitting
Stealing items
Tantrum
Throwing items
Any additional behaviors/concerns:
Is your student bathroom trained?
Yes, #1 only
Yes, #2 only
Yes, both
No
When your student engages in behaviors, what do you think causes them?
When your student engages in behaviors, what do they look like? How long do they last?
What helps the student calm down after engaging in behaviors?
What behavioral interventions work best for your student? (Ex. Time-out, extinction/ignoring, redirection, etc.)
Any additional comments regarding your student's behavior:
Does Beyond the Spectrum have your permission to contact previous schools, therapists, or service providers to learn more about your student?
Yes
No
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