Intake Form
Behaviour Consultation, Parent Coaching, Clinical Services
I am a... [Client requesting services/Parent or caregiver/ Medical Professional or Community Agency]
*
Please Select
Client requesting services
Parent or caregiver
Medication professional or community agency
Date of Birth of the individual being referred
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What type of services are you wanting to access? Are you looking for virtual/in-person/other settings?
ABA/ IBI Behaviour Consultations/ Parent Coaching/Education/ Clinical Services/Supervision/ Mental Health and Wellness/ Medication Consultation.
Parent or Caregiver Information / Medical Professional Information/Community Agency and Contact Information
Name
*
First Name
Last Name
Main Phone
*
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Email
*
example@example.com
Consent
I have consent from the individual or their legal guardian to request services
*
Please Select
Yes
No
N/A
Relationship to the client
*
Email
Preferred Method of Contact
Please Select
Main Phone
Cell Phone
Email
Organization
Job Title
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Support/Accommodation Needs
Client Information
Client Name
*
First Name
Last Name
Preferred Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Female
Male
Gender Non-conforming
Non Binary
Two-Spirit
Prefer not to say
I identify as...
I identify as...
Main Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Pronouns
Race, ethnic or cultural background (select all that apply):
Black/African American
East Asian
Indigenous
Middle Eastern
South Asian
White / Caucasian
Hispanic / Latin America/ Latino / Latinx
Other
I do not know
Prefer not to say
Other (Specify):
Preferred Method of Contact
Please Select
Main Phone
Cell Phone
Email
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Address
Same as Parent or Caregiver
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Card Number
Version
Family Doctor [Name/Location]
*
What is the name of the school the student is currently attending? (if applicable)
Referral Name
First Name
Last Name
Preferred Time of Services - AM 9am-12noon/ 1pm-4pm (Specify):___________
Provincial Funding Information
Ontario Autism Program(OAP) Number [If known/applicable] - Direct Funding or Fee-for-Service Funding option?
This number is issued after registering with the Ontario Autism Program.
Ontario Disability Support Program Member ID (If Applicable)
This is a 9-digit number issued to ODSP members.
Insurance Information
Name of Insurer
First Name
Last Name
Insurer Phone Number
Format: (000) 000-0000.
Policy Number
Group Number
Client Support Needs
Confirmed or suspected diagnoses
Autism Spectrum Disorder (ASD)
Attention-deficit/hyperactivity disorder (ADHD)
Oppositional Defiant Disorder (ODD)
Other intellectual or developmental disabilities
Do you have any physical health conditions or chronic illnesses?
Yes
No
List any physical, visual, hearing, or other supports required
How would you describe the client's strengths and interests?
Please let us know about any behaviour/communication/safety concerns or sensory needs.
Are there any allergies, medications or other concerns we should know about?
Has the client participated in any Ontario Autism Program (OAP) before (e.g., Speech and Language Pathologist-SLP/ Occupational Therapist-OT etc.)?
Yes
No
If yes please specify:
What are some goals that you have for the client?
Mental Health and Wellness Services
Mental Health and Wellness Services
Reason for Seeking Care (Check all that apply)
Anxiety
Depression
Trauma/PTSD
Relationship Issues
Grief and Loss
Anger Management
Substance use
Self-esteem issues
Other...
Please describe in your own words the issue(s) you would like help with:
Mental Health History
Have you previously sought therapy or counselling?
Yes
No
If yes, please provide details (e.g., type of therapy, how long ago, results):
Do you have any previous diagnoses (e.g., depression, anxiety, PTSD, etc.)?
Yes
No
If yes, please provide details (dates, reasons, treatment):
Have you ever been hospitalized for mental health issues?
Yes
No
If yes, please provide details (dates, reasons, treatment):
Do you have a history of mental health issues in your family?
Yes
No
If yes, please specify:
Do you have a good support network (friends, family, etc.)?
Yes
No
Unsure
Are you currently taking prescription medication?
Yes
No
Please Specify:
Prescribing Doctor's Name
First Name
Last Name
Prescribing Doctor's Phone
Format: (000) 000-0000.
Reason for seeking help
Goals for Therapy?
Current Symptoms
Please check any symptoms you have been experiencing recently:
Feelings of sadness or hopelessness
Panic or anxiety attacks
Difficulty concentrating
Fatigue or lack of energy
Trouble sleeping or sleeping too much
Irritability or anger
Decreased interest in activities
Thoughts of self-harm or suicide
Other symptoms:
If you require emergency services and have an urgent concern about your well-being or the safety of others, please visit your local hospital or dial 9-1-1, text/call 9-9-8 for the 24/7 Mental Health and Suicide Prevention Hotline, contact the Kids Help Phone at 1-800-668-6868, or Community Crisis Response Service at 1-855-310-COPE (2673) serving Durham and York regions.
OTHER INFORMATION
Please let us know other information you would like to share that may be useful to the intake process.
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