New Client Intake Appointment
To schedule an a new client intake appointment, please complete the following questions. Both you and your child/client must be present during the intake. *All intakes are done in-person at the Amplify Life office*
Is your son/daughter 16 years or older?
*
Yes
No
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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).
Have your child/participant ever been in trouble with the law?
*
Yes
No
If "yes", please explain (how long ago, what was the situation).
Is your child/participant prone to seizures?
*
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. Both you and your client/child must be present for the intake.
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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.
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At this time, your son/daughter does not meet the age requirement for Amplify Life programs, as participants must be at least 16 years old.
We apologize for any confusion and truly appreciate your interest in our programs. Once your son/daughter reaches the eligible age, we would love for you to register again, and we’ll be happy to connect with you then.
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Thank you for your interest in Amplify Life!
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