Academy Intake

Today's Date

MonthDayYear
Date
Enrolling School Year
General Information (PLEASE PRINT)
Child's Name
Date of Birth

MonthDayYear
Date
Age
Present Grade
Enrolling Grade
Height
Weight
Current School (if applicable)
School Address and Phone
Format: (000) 000-0000.
School County
Does the child have an IEP?
How did you hear about us?
YesNo
YesNo
YesNo
Matrix Number ( this will bea 251, 252, 253, 254 or 255). Your current school or district can give you thisinformation
K-12 3100 Fruitville Sarasota, Fl 34237 inside the Boysand Girls Club350 Braden Avenue Sarasota, Fl 34243 There are only 3 classes at this location. 8thgrade to 22 years of age. A life skills class, an academic access class and avocational on the job training and community based instruction class for 18-22year olds.
Parent/Guardian(s) Requesting Information, Tour, or Placement (PLEASE PRINT ALL INFORMATION)
Name
Relationship to Student
Contact Phone Number
Format: (000) 000-0000.
Contact email
example@example.com
Student's Address
Intake Questionnaire
At Easterseals Academy, we offer unique specialized educational programs. Please note, some questions may not be relevant to your child. Please answer all applicable questions thoroughly and to the best of your ability so that we may better understand your child’s individual circumstances, needs, and goals. Thank you
Child Diagnoses

The diagnoses listed below are divided into categories. Please circle all diagnoses that apply to your child.
Developmental or Neurological-Related Diagnoses

The diagnoses listed below are divided into categories. Please circle all diagnoses that apply to your child.
AutismAsperger'sDown's SyndromeSeizure DisorderFetal Alcohol SyndromeOther
ApraxiaGross Motor DelayFine Motor DelayCerebral PalsySensory Integration DisorderOther
DyslexiaDysgraphiaDyscalculia
General Anxiety DisorderPanic DisorderDepressionSeparation AnxietySocial PhobiaBipolar DisorderObsessive Compulsive DisorderTourette's SyndromePTSDOther
Attention Deficit- HyperactiveAttention Deficit- InattentiveAttention Deficit- CombinedOppositional Defiance DisorderOther
YesNo
If yes, what do you call it or refer to it as?
AsthmaAllergiesDiabetesHeart ConditionOther
Please list any FOOD allergies that your child has
Please list any NON FOOD allergies your child has
If your child has allergies, what are the signs and symptoms of an allergic reaction?
YesNo
Any other medical conditions or health concerns
Dietary Restrictions or Needs
YesNo
If yes, please describe
Medications- Please list all medications that your child takes regularly.
Please list: Name of Medication,Dose,Frequency and Prescribing Physician
HeadachesSensitive to soundDark under eye circlesFrequent DiarrheaMood SwingsFrequent constipationRefusal to eatHyperactivityAcid RefluxEczemaTires EasilyFrequent ear infectionsChronic congestionsSeasonal AllergiesBruises easilyNeeds assistance with toileting
Any additional notes or concerns regarding your child's health or medical conditions.
Is your child potty trained? Does he need assistance in the bathroom ?
ABA Therapy (Behavioral Therapay)Music TherapyOccupational TherapyPhysical TherapySpeech and Language TherapyOther
Any additional notes regarding services or therapies that your child receives
If you are not currently receiving services or are interested in receiving Speech, OT, ABA, PT or hippotherapy at Easterseals please provide your insurance information.
Type of Insurance
Policy #
Policy Holder's name
D.O.B.
Carrier
Medicaid ID
Academic Profile To the best of your knowledge, please select what your child can do independently. Please note, this is not a comprehensive list of all academic skills, but rather a way for us to have an idea of your child's academic abilities.
Identify LettersRead sight wordsRead sentencesRead short booksRead chapter booksWrite his/her nameWrite complete sentences
Approximate grade level for Reading and Writing
Identify numbersCount to 10Count to 100Basic AdditionBasic SubtractionBasic MultiplicationBasic Division
Mathematics: Approximate grade level
Any additional comments regarding your child's academic progress:
AnxiousConfidentTalkativeQuietLeaderFollowerIndependentDependentSensitiveAggressiveActiveNon-ActiveOutgoingShyMoodyEven-TemperedPlayfulSeriousAnalyticalImpulsive
Any additional comments
SOCIAL SKILLS AND TENDENCIES Please select which of the following your child enjoys.
Does your child usually prefer to be alone or with others?
Does your child initiate interaction with parents/guardians?
Does your child initiate interactions with other adults?
Does your child initiate interactions with siblings?
Does your child initiate interactions with peers?
What does your child like to do alone?
What does your child like to do with others?
Any additional comments
ArticulationFluency of SpeechVoice DisorderApraxiaStutteringAuditory Processing DisorderDeaf/Hearing LossScripting or EcholaliaOther
Has no verbal languageHas limited verbal languageCan Answer Basic QuestionsIs conversationalCommunicates in full sentencesIs difficult to understandUses PECS to communicateUses devices to communicateUses sign LanguagePoints to what he/she wantsUses gestures (head shake)Does not voluntarily speak
Executive Functioning
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
AlwaysOftenRarelyNever
Yes, Full timeYes, Part-timeNo
Any additional comments or concerns regarding your child's executive functioning skills?
Behavior Profile
YesNo
YesNo
YesNo
YesNo
If yes, please explain
Hit- open handHit- closed fistKickingBitingThrowing itemsStealing itemsExcessive lyingScratchingSpittingPinchingHead BangingTantrumsRunning awayDamage propertyRefuse to do tasks
Any additional behaviors or concerns:
When your child acts out, what do you think usually causes it?
When your child acts out, what does it usually look like?
When your child acts out, how long does it usually take until he/she calms down?
When your child acts out, what usually helps to calm him/her down?
What behavioral interventions work best for your child? (such as ignoring, time out, redirection, etc.)
Any additional comments or information regarding your child?
Should be Empty: