Child Intake Form

Child Intake Form
Child Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Diagnosis (if known):
Parent or Guardian 1:

First NameLast Name
Parent or Guardian 2:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact Name:

First NameLast Name
Emergency Contact Relationship to Child:
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.

Doctor/Specialist Information
Primary Doctor:

PrefixFirst NameLast Name
Primary Doctor Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Doctor Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Doctor/Specialist 1:
  
  First NameLast Name
- Doctor/Specialist 1 Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Doctor/Specialist 1 Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Doctor/Specialist 2:
  
  First NameLast Name
- Doctor/Specialist 2 Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Doctor/Specialist 2 Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code

Family Background
Parent or Guardian 1 Name:

First NameLast Name
Parent or Guardian 1 Age:
Parent or Guardian 1 Occupation:
Parent or Guardian 1 Education Level:
Parent or Guardian 2 Name:

First NameLast Name
Parent or Guardian 2 Age:
Parent or Guardian 2 Occupation:
Parent or Guardian 2 Education Level:
Current Marital Status:
Which adult(s) does your child live with? Check all that apply:

Other
Language(s) spoken in the home:
Who speaks the other language(s)?
Describe the client's use/understanding of the language(s):
Is there anything additional you would like to share about the family/home environment?

Educational History
Is the child currently enrolled in daycare or school?
What is the name of the daycare?
What is the name of the school?
What day(s) do they attend?
e.g. Monday to Thursday, or weekends only.
What is the child's grade level?
Does your child have an IFSP or IEP?
Is your child in a special class setting?
What type of class setting is your child enrolled in?
ICT, 8:1:1, 12:1:1, other
Describe any accommodations your child receives:
Describe any educational difficulties or learning challenges that your child has experienced:

Social History
Describe how your child interacts with parents, siblings, or other family members:
Describe how your child interacts with other children or non-family members?
Are there any significant events or changes within the home?
What are your child's strengths?
What are your child's weaknesses?
Does the child have any favorite activities?
Does the child participate in any community activities or sports?
If so, please describe:
What are your goals for your child over the next 6 months?

Doctor/Specialist Information