Client Intake Form

Client Intake Form

Kelsey Smith Advocacy
Student Name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
Date
Special Education eligibilities under 504/IEP (If initial testing has not occurred, please let me know.)
Mother's Name

First NameMiddle NameLast Name
Mother's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Date of Birth

MonthDayYear
Date
Mother's Email
example@example.com
Mother's Occupation
Father's Name

First NameMiddle NameLast Name
Father's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father's Date of Birth

MonthDayYear
Date
Father's Email
example@example.com
Father's Occupation
Marital status of Parent(s)
If parents are divorced, who has primary conservatorship of this child? (If so, include copy of divorce decree section with opening documents.)

Other
Current Needs
Does your child currently have a chronic medical, genetic, developmental, or mental health diagnosis? If yes, please explain.
Does your child have functional needs?
What are your current concerns about your child?
How long has your child had the problems you described?
How does your child play? (For example: pretend, interactive play, repetitive play, line up items, no interest in toys, parallel play next to friends, etc)
Does your child repeat behaviors? If yes, please explain. Does your child get stuck on certain activities? If yes, please explain.
Does your child enjoy unusual items? (Example: gravel, street signs, paperclips, string, etc.) If yes, please explain.
Does your child get upset if things are not "just so"? If yes, please explain.
Behavioral & Developmental Needs
How does your child interact with you?
How does your child interact with other adults he/she knows?
How does your child interact with children he/she knows?
Does your child have a problem with eye contact? If yes, please explain.
Has your child ever been hospitalized for behavior or emotional problems? If yes, please explain.
Does your child have a history of or is your child currently engaging in self-injurious or aggressive behaviors? If yes, please explain.
Medical History
Please list all prescribed medications, as well as any over the counter vitamins or supplements you child takes.
Please list any other providers/therapists involved in the care of this child, along with their specialty and phone numbers. (For example: Developmental Pediatricians, Psychologists, Psychiatrists, Geneticists, Pediatric Neurologists, Pediatric Gastroenterologists, Neurosurgeons, Therapists (Speech, Occupational, Physical), Counselors, ABA facility, etc.)
Developmental Milestones: Please list the age at which your child accomplished and/or did not meet developmental milestones.
Please indicate whether your child has ever been diagnosed with any condition:

Has anyone in your family experienced the following? (Biological Relationship to child)

Rows	Yes
Learning Problems
ADHD
Intellectual Disability
Down Syndrome
Speech Impairment
Birth Defects
Cerebal Palsy
Tourette's Syndrome- Tic Disorder
Neurological Disorder
Epilepsy/Seizure Disorder
Bipolar Disorder
Depression
Panic Attacks
Anxiety
Obsessive Compulsive Disorder
Schizophrenia
Genetic Syndromes
Muscle/Motor Problems
Dyslexia
Other

If Other, please list:
Educational History
School District and State
Child's Current School
School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Grade Level
Teachers
Present Class Placement
Has special education/504 testing been completed by the school? If yes, when?
Is your child currently on an IEP/504 plan at school? (If yes, I will need a copy of the school evaluation.)
Has your child ever been retained?
If yes, what grade and why?
Please describe any ACADEMIC school problems and/or needs.
Please describe any BEHAVIORAL school problems and/or needs.
Please describe any FUNCTIONAL school problems and/or needs.
Educational Programs
Has your child ever participated in any of the following educational programs?

Other
Behavior & Discipline
Please briefly describe any BEHAVIORAL problems at home.
Types of discipline you use with your child: (check all that apply)

Other
Which form(s) of discipline has proven most effective?
Please provide additional information about any of the above you feel would be helpful.
Recent Events
Have any of the following events occurred within the past 12 months?

Other
If Other, please explain.
Please write any additional questions, comments, or concerns you may have regarding your child that we may have missed:
**PLEASE READ CAREFULLY!**

If you are divorced, you must send a copy of your divorce decree section to allow me to confirm which parent(s) have the right to consent to educational decisions for the child. * If your child is receiving special education/504 services, please send a copy of the 504/FULL AND INDIVIDUAL EVALUATION (FIE). This is the comprehensive evaluation that would have been conducted to initially qualify your child for special education services in school, PPCD, or PALS. * If you have requested and/or been denied an evaluation through your child's school please have the school provide a statement on school letterhead regarding their refusal to evaluate your child, or a statement regarding why they feel a full individual evaluation is not necessary.
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Client Intake Form

Current Needs

Behavioral & Developmental Needs

Medical History

Educational History

Educational Programs

Behavior & Discipline

Recent Events

**PLEASE READ CAREFULLY!**

PLEASE READ CAREFULLY!