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 does the client live with? Check all that apply:*

Birth Parent(s)Adoptive Parent(s)Foster Parent(s)Grandparent(s)Both Parents/GuardiansParent/Guardian 1 OnlyParent/Guardian 2 OnlyOther
If the client has any siblings, please list them here:
Include their name, age, and any speech issues they may have.
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?*

DaycareSchoolNeither
If enrolled in daycare, what is the name of the program they attend?*
If enrolled in school, what is the name of their school?*
What day(s) do they attend?*
e.g. Monday to Thursday, or weekends only.
What is the child's grade level?*
What is the type of classroom they attend?*
Please describe any accommodations they may receive:
Please describe any educational difficulties or learning challenges that this child has faced:

Social History
Describe how the child interacts with parents, siblings, or other family members:*
Describe the communication difficulties the child faces in the home environment:*
Are there any significant events or changes within the home?
What are the child's strengths?*
What are the child's weaknesses?*
Does the child have any favorite activities?*
Does the child participate in any community activities?*

YesNo
If so, how is their behavior or communication when participating in these activities?
Does the child become easily frustrated with certain activities?*

YesNo
If so, describe why?
How does the child interact with other children?*
What are your goals for the child over the next 6 months?*
What are your goals for the child over the next 5 years?*

Doctor/Specialist Information