TwiddleU Learning Academy Intake Form
Please answer as accurately as possible. This information helps our teachers, administrators, and staff with determining the resources needed for your child. If enrolling multiple children, please complete one intake form per child.
Name of caregiver completing this form
*
First Name
Last Name
Relationship to child
*
Child's Name
*
First Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade your child will be entering this year
Please Select
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Number of children in household
*
Please Select
1
2
3
4
5
6
7
8
9
10
Number of children that reside with you more than 6 months out of the year.
Select the option from each row that best fits your child
*
Never
Sometimes
Often
Has long intense meltdowns
Runs away for no particular reason
Struggles with sharing
Struggles with understanding other people's feelings
Enjoys playing with or alongside other children
Shares toys easily
Struggles to get along with other children
Understands the concept of "yours" and "mine"
Becomes overwhelmed easily
Is overwhelmed by loud noises
Struggles to understand and follow rules
Is sensitive to bright lights
Is overwhelmed by big crowds
Verbally communicates
Uses sign language to communicate
Uses a communication device
Vocalizes loudly at seemingly inappropriate times
Engages in self injurious behavior (ex: head hitting, scratching, biting, hair pulling)
Engages in harmful behavior with others (ex: biting, hitting, scratching, hair pulling)
Places non food items in mouth
Uncomfortable when they cannot see their caregiver
Has food aversions
Please provide the child's current autism diagnosis level (if given one) and all other current diagnoses
*
If no diagnosis, please put N/A.
What are your biggest challenges when you go out in public places with your child?
Does your child currently have an active IEP, 504 plan, or behavioral plan?
*
Please Select
Yes
No
If yes, please email them to contact@twiddleu.org.
Does your child take any medications?
*
If no medications, please put no. If yes, please list medications and when they must be administered.
Does your child have any allergies?
*
If no allergies, please put no. If yes, please list allergies.
Submit
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