New Driver Intake

NEW DRIVER NON ADAPTIVE INTAKE FORM
Our program is a specialized investment in the safety, confidence, and long-term independence of each new driver. We provide individualized instruction for clients who experience challenges or barriers to driving that are not typically addressed by traditional driving schools.

We are the only driving school in Iowa that provides this level of specialized driver education and support. All instructors receive advanced training, and instructional vehicles are equipped with safety-enhancing equipment.

Every driver is unique. We do not compare clients, and there is no guarantee of licensure.

Honest and complete responses are essential. The information you provide allows us to design the safest and most effective instructional plan possible.
Form Element: Checkbox (Required – must select all)
*
SECTION 1 — CLIENT INFORMATION (REQUIRED UNLESS NOTED)
Client Age Category*
Client Legal First Name*
Client Legal Middle Name*
Client Legal Last Name*
Client Preferred NickName
Date of Birth*

MonthDayYear
Date
Gender*
Height*
Weight*
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
Please avoid using a school-issued email address if applicable.
Address of Client*

Address

Street Address Line 2

CityState

Zip
Parent/Guardian #1*

First NameLast Name
Parent #1 Cell - *
Please enter a valid phone number.Format: (000) 000-0000.
Parent #1 Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact*
Please enter a valid phone number. Format: (000) 000-0000.
Emergency Contact Email*
example@example.com
This form must be completed electronically. THIS IS A CONFIDENTIAL FORM between you and the Driver Rehabilitation Professional.
In High School? Yes No (circle one) If yes, what was last grade completed*
Last Grade Completed*
If graduated, Type NA
Name of School?*
City/State*
Does Client have an IEP or 504 plan?*
FAMILY
1. Do you have any brothers or sisters that drive?*
2. Do you enjoy riding with them?*
3. What kind of vehicle do your parents drive?*
Select only one
4. What would you use a driver license for?*
5. What makes a driver’s license important?*
6. Do you think you can follow all the rules associated with driving a vehicle?*
7. If it takes 3-6 months to learn to drive, are you ok with that?*
8. Driving takes a lot of instruction and practice. Are willing to do this?*
9. Do you have a parent/guardian or relative you can practice driving with?*
10. Do you understand that there may be several driving restrictions if you get license?*
11. Do you understand that there is no guarantee you will get a driver’s license?*
12. Do you want to be a safe and responsible driver?*
13. What are your fears about driving?*
PERSONAL ABILITIES/APTITUDES/INTERESTS:
14. What skills are you good at?*
15. Do you like to observe or do things with your hands?*
16. What makes you happy?*
17. What makes you frustrated or upset?*
18. What worries or concerns you?*
19. What would your family/friends says is your most likable trait?*
20. What are your hobbies/favorite things to do?*
21. Do you listen to music? If so, who?*
21A. Musical Artists*
Type NA if you do not listen to music
22. Do you watch TV/Movies? If so, what are your favorites?
22A. Favorite TV Shows or Movies*
Type NA if you do not watch TV or Movies
23. Do you play video games? If so, what?*
23A. What Video Games do you play?*
If you do not play video games, Type NA
24. Do you play video games on your phone? If so, what?*
24A. Games on your phone*
Type NA if you do not play games on your phone
25. What things do you get excited about?*
26. Are there any things that you would like your driving instructor to know about you that can help them be a better teacher for you?*
Medical Information
Do your wear glass or contacts?*
Are you hard of hearing or deaf?*
Have you ever had a concussion?*
If you have had one, or multiple? Please state month and year.
Ever had a seizure?*
If had a seizure, please state date of last one and if you are taking any medications
Do you have any allergies?*
If you have allergies, please state what to and any medication required.
This form must be completed electronically. THIS IS A CONFIDENTIAL FORM between you and the Driver Rehabilitation Professional.
SECTION 2 — PERMIT / LICENSE INFORMATION
Do you currently have a learner’s permit?*

YesNo
If so, Please enter your Instructional Permit Number here.
Numbers and letters are required
Please state the Issue date and expiration date

MonthDayYear
Date
Please state the Expiration date

MonthDayYear
Date
Do you currently have a driver’s license?*

YesNo
If so, Please enter your Driver's License Number here. Please include dashes, Issue date and expiration date
Should be Empty:

NEW DRIVER NON ADAPTIVE INTAKE FORM

Form Element: Checkbox (Required – must select all)

SECTION 1 — CLIENT INFORMATION (REQUIRED UNLESS NOTED)

FAMILY

Medical Information

SECTION 2 — PERMIT / LICENSE INFORMATION