New Client Intake Appointment
To schedule an a new client intake appointment, please fill out the information below. Both you and your child/client must be present during the intake. *All intakes are done in-person at the Amplify Life office*
Appointment Details
Please select an appointment date and time
*
Client Information
Please provide some information on your child/participant.
Client Name
*
First Name
Last Name
Client Age
*
Primary Diagnosis
*
What high school does/did they attend? What class are/were they in?
*
High School
Class (e.g., CLS, Strategies, Social Resource...)
Do/Did they have a 1:1 aide at school?
*
Yes
No
Are they independent in the restroom?
*
Yes
No
Do they show/have an aggressive behaviors towards themselves or others?
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Yes
No
If "Yes", please explain examples of the behaviors that are seen (ex: physical harm, inappropriate/crude behavior, self-harm).
Is your child/participant prone to seizures?
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Yes
No
If your child/participant is prone to seizures, are they controlled by medication?
Yes
No
Parent/Caretaker Information
Please provide your information.
Name
*
First Name
Last Name
Relationship
*
Parent
Family Member
Caretaker
Case Manager
Self/Own Guardian
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Are there any programs in specific you are interested in?
(e.g., Friendship & Dating, Cafe Canteen, Physical Health, WORKS! Camp, Social Programming...)
Are there any programs in specific you are interested in?
*
Social Programming
Independent Living
Meaningful Wednesdays
Cafe Canteen
Works! Camp (ages 14-21)
Anything & Everything
Not Sure - I need more information
How did you hear about us?
*
Friend
Family
Social Media
Regional Center
School
Other
New Client Intakes are done in person at the Amplify Life Office (Office Door #1) Both you and your client/child must be present for the intake.
If you have any questions, please call the office at (775) 827-3866
Once you submit, you will receive a confirmation email for your appointment, along with an attachment of directions to our office.
We are the big white building with the green trim on the Northern Nevada Adult Mental Health Services Campus. Please knock on the Office Door (#1).
Submit
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