Community Services Parent Intake Form

Community Services

Parent Intake Form
Psychology Groups

Thank you for your interest in our Community Services programs. Please note this intake form is only for application to psychology programs.

Inquiries for the Read/Write program can be sent to rwmintake@foothillsacademy.org

Inquiries for our Amicus Camps and Recreation can be sent to intake@foothillsacademy.org

Please note all applicants must meet the following intake criteria in order to be considered for intake approval:

Diagnosed Learning Disability and/or ADHD - Learning Disability and/or ADHD must be diagnosed by a psychologist or pediatrician (ADHD only) and is considered to be the child's primary diagnosis.
Average to above-average IQ - A full-scale IQ (FSIQ) or general ability index (GAI) of 85 or above as indicated in the psycho-educational assessment.
No significant emotional or behavioural regulation challenges - The individual is able to participate in a 3:1 child to staff member ratio.
Participants are able to stay in large groups consistently - The child will be in groups of up to 36 campers for some components of Amicus summer programming and up to 12 participants for Psychology groups.

You can view the full intake criteria on our website by clicking HERE.

If you have any questions, comments, or concerns about the intake process, please contact our Intake Coordinator, Jana Stevenson, at intake@foothillsacademy.org

Today's Date*

Date

Program Inquiring About (Select all that apply)*

Girls Only

Child's Legal Name*

First NameLast Name

Child's Preferred Name

Child's Date of Birth*

Date

Child's Age*

Child's Sex*

MaleFemale

Child's Gender Identity*

Child's Diagnosis(es) - Select all that apply. If you do not see a diagnosis listed, please select 'Other' and provide the name*

ADHD (Combined, Inattentive, Hyperactive-Impulsive)Learning Disability (Including Writing, Reading, and Math)Anxiety DisorderAutism Spectrum DisorderDevelopmental Coordination DisorderOppositional Defiant DisorderOther

Is your child aware of his/her/their diagnosis(es)? LD/ADHD diagnosis/strategies will be discussed in our programs. *

If your child is unaware of any of their diagnoses, please specify which.

Full Name of parent/guardian completing this form*

First NameLast Name

Email address of parent/guardian completing this form:*

example@example.com

Phone number of parent/guardian completing this form:*

Please enter a valid phone number.

Please provide the full names and status (i.e. married, separated, partial custody) of any other parents, guardians, or individuals who have legal custody of this child*

Child's School*

Grade*

Please describe your child's school setting (i.e. regular or specialized classroom)*

Please describe how your child is doing socially and behaviourally at school*

Does your child have an Individual Program Plan (IPP) or Learner Support Plan (LSP) at school?*

YesNo

Does your child currently have an aide in school?*

Yes - They have their own assigned aideYes - There is an EA/aide helping the classNo

What does the aide assist them with (whether an assigned individual or classroom aide)?

AcademicsOrganizationFocusBehaviour

If your child has their own aide, is the aide:

Full-timePart-time

Does an aide go to the playground with the child?*

YesNo

If your child does not have an aide, do you think they would benefit from one and in what areas would the aide support the child (academics, organization, focus, behaviour)?

Please describe your child's behaviour at home*

What are your biggest concerns regarding your child right now?*

What would you like for your child to get out of this program?*

Would you anticipate any difficulties with your child being in a large group over 50% of the time that they are at our program? Group sizes are typically 8-12 for Psychology Groups, 15 for Recreation Programs, and 20-35 for Camp Programs.*

Are there any current difficulties in the family that may affect your child at our program (i.e. their or a family member's health, financial stress, marital situation, death in the family)?*

Is there a history of suicidal thoughts or behaviours that we need to be aware of?*

Please use the table below to decribe your child in relation to the following statements:

Severe Problem: The child shows a severe deficit in this area compared to other people his/her/their age

Moderate Problem: The child struggles with this area either somewhat consistently, or rarely struggles with this area (less than once every 3 months), but when it does come up it is not easily supported.

Minor Problem:The child has some difficulty in this area compared to other people his/her/their age

No Problem: The child has no difficulty in this area (i.e. average or better compared to others their age)

Please use the table below to describe your child in relation to the following statements:*

	Severe Problem	Moderate Problem	Minor Problem	No problem
Easily Frustrated
Listens to and accepts direction from adults
Resists trying new things
Short attention span
Hurts others physically when frustrated/angry
Hurts self physically when frustrated/angry
Impulsive behaviour
Tendency to cry easily
Mood changes quickly and drastically
Verbal outbursts when frustrated
Difficulty with transitions
Very sensitive to noise, texture, etc.
Runs away/hides when stressed (in the last 6 months)
Rigid thinking (black & white thinker, my way or the highway)

For any areas that were marked severe or moderate, can you please elaborate with more details? (i.e. frequency, how the child is supported when this behaviour occurs, certain triggers, etc.)*

If none were marked severe or moderate, please enter N/A

If your child struggles with transitions, please describe when this happens and how you handle it*

If transitions are not a challenge, please enter N/A

If your child has a recent history of running away or hiding when stressed, please describe*

If your child does not have a history of running away or hiding when stressed, please enter N/A

If your child has previously been enrolled in one of our Community Services programs (Let’s Be Social, Camp Amicus, Read/Write, etc.), please check the 'Yes' box below to give permission for current program staff to access information in your child’s program file or former program staff.*

YesNoMy child has not attended any of these programs before

If your child is a student at (or has applied to) Foothills Academy, please check the 'Yes' box below to give permission for current program staff to access your child's psycho-educational assessment and IPP.*

YesNoMy child does not attend and has not applied to Foothills Academy's school program

In order for us to make the best decision about the appropriateness of this program for your child, getting your child’s teacher’s perspective can be helpful. Do you give permission for current program staff to contact your child's teacher?*

YesNo

Parent/Guardian Signature*

Document Submission

All intake packages must include the submission of the following:

Parent Intake Form - Our Intake Coordinator will automatically receive this form once you click submit
Teacher Intake Form - See highlighted portion below
Psycho-educational Assessment - if your child has not received a psych-ed assessment, we can alternatively accept a pediatrician letter/report confirming diagnosis
IPP/LSP - if you noted your child does not have an IPP, this piece will be excluded from the intake package

Please forward this link to your child's teacher - it is an intake form to gain the teacher's perspective and will be automatically returned to us once they submit: https://hipaa.jotform.com/223385025045248

Please use the file submission box below to upload any documents you are ready to submit at this time. If you do not have these documents on-hand or have any issues uploading the file, please email them directly to Jana at intake@foothillsacademy.org

Please provide any passwords to protected documents

Please upload a copy of your child's psych-ed assessment, pediatrician letter, IPP, or any additional documentation you wish to provide below.

Thank you for completing the intake form. Please hit 'Submit' and our Intake Coordinator should be in touch within the week.