Exceptional Learners (Part of Safer Driver - IA) - IVRS or Private Pay Referral Form

NEW DRIVER INTAKE FORM

If some questions are difficult to answer or are not applicable, skip them, we can come back to them later. These questions are designed to give the driving instructor information about the student. This information provides the instructor with critical data when developing the Individualized Drivers Education Plan (IDEP). The more accurate information we have about the student, the better the Individualized Driving Plan can be. Parent information is relevant for all individuals under 21 as emergency contact information. All clients need to list at least one emergency contact regardless of age.
IVRS Counselor Name (if private pay - parent name)*

First NameLast Name
IVRS Counselor Phone # (if private pay - parent phone)*
Please enter a valid phone number.
IVRS Counselor Email (if private pay - parent email)*
example@example.com
IVRS Office Location (if private pay - parent address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Name*

Legal First NameLegal Middle NameLegal Last Name
Preferred Name/ Nick Name
Preferred Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Counselor email or if private pay parent email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleTransgenderOther
Wear Glasses/Contacts?*
Do you have any medical or physical conditions that we should be aware of?
Other Lead Source
Do you have a permit/license?

YesNo
Do you need us to schedule a permit test for you?

YesNo
Permit/license #
Permit/license Issued Date

MonthDayYear
Date
Permit/license Expiration Date

MonthDayYear
Date
Are you in high school?

YesNo
High School (If applicable)
IEP/504

YesNo
Have you had a seizure?

YesNo
If yes, date of last seizure

MonthDayYear
Date
Do you have Epilepsy?

YesNo
Diagnosis
ADHD
Anxiety
Autism
Color Blindness
Other Eye Conditions
Dyslexia
Hard of hearing/deaf
Concussion
Date of Concussion

MonthDayYear
Date
Physical Disabilities
Allergies
Allergies Type
Cognitive Disabilities/Executive Functioning
What kind of vehicle do your parents drive?*
Do you have siblings

YesNo
Siblings Ages

Under 18Over 18
Do any of your siblings drive?

YesNo
Why do you want a drivers License?
Given time and patience, Do you think all the rules associated with driving a car?

YesNo
If it takes 3months to learn to drive, are you willing to put in the time?

YesNo
Driving takes a lot of instruction and practice, are you willing to do this?

YesNo
Are you able to practice 15 minutes a day with your parents?

YesNo
What concerns you have about Driving?
There will be an online course to teach you about Traffic safety. Are you willing to do this?

YesNo
Do you like to watch or do things with your hands?
Would you eventually like to travel to other towns?

YesNo
Where?
Tell us anything about yourself that you would like to share , or that you think the instructor should be aware of, which might help them to know you better or enable them to be more effective driving instructor for you.
Parents/Guardians, Is there anything else the we should be aware of that might affect/enhance our driving program for the student above?
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Cell # *
Please enter a valid phone number.
Parent/Guardian email*
example@example.com
Parent Name 2

First NameLast Name
Parent Phone 2
Please enter a valid phone number.
Parent/Guardian Email 2
example@example.com
Emergency Name*

First NameLast Name
Emergency Relationship*
Emergency Phone *
Please enter a valid phone number.
What makes you happy?
What makes you mad/angry?
What worries or concerns you?
What movies/tv shows/music do you like?
Do you play video games?

YesNo
What video games do you play?
What are your hobbies/favorite things to do?
Do you have job?

YesNo
If you don't have a job, Are you still in school?

YesNo
If you don't have a job, are you planning to get a job?

YesNo
Please verify that you are human*
Should be Empty:

NEW DRIVER INTAKE FORM