Inclusion Infusion Academy
Pilot Program Intake Form
Personal Information
Please fill out the clients information
Clients Name
*
First Name
Last Name
Clients Age
*
Gender (Optional)
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Information
Parents/Guardian Name
*
First Name
Last Name
Relationship to client
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best Method of Contact (Phone, Email, Text, etc.)
*
Current Support System
Does the client currently have a Direct Support Professional (DSP)?
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Yes
No
If yes, provide DSP Name and Contact Information
Is the parent/guardian involved in the client’s daily support?
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Yes
No
How involved is the parent/guardian in goal setting and implementation?
*
Very Involved
Moderately Involved
Not Involved
What are the client’s primary goals? (Check all that apply)
*
Getting Driver’s License
Graduating High School
Preparing for Post-Graduation Employment
Independent Living Skills
Other
Please describe any other specific goals the client is working on
Availability
How many hours per week is the client available to work on these goals?
*
Preferred time of day for support
*
Morning
Afternoon
Evening
Motivation and Commitment
How motivated is the client to achieve these goals?
*
Very Motivated
Somewhat Motivated
Not Motivated
What challenges is the client currently facing in achieving their goals?
*
Why do you think the client needs this program at this time?
*
Parent/Family Feedback
How comfortable are you with providing regular feedback on the program’s effectiveness?
*
Very Comfortable
Somewhat Comfortable
Not Comfortable
Are you willing to actively participate in the development and adjustment of the program based on your child’s progress?
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Yes
No
What are your expectations for this program, and how can we best support your child’s growth and development?
*
Additional Information
Is there anything else we should know about the client or family in order to provide the best support?
By checking this box, I consent to receive SMS messages, phone calls, and emails from Inclusion Infusion Allies at the phone number and email address I provided. These messages may include updates about programs, events, and other relevant information. Messaging frequency may vary. Message and data rates may apply. I understand that I can opt out of SMS messages at any time by replying STOP or request help by replying HELP or visiting https://www.inclusioninfusion.org.I have reviewed and agree to the Privacy Policy and Terms of Service. I understand that my phone number and SMS consent will not be shared or sold. Checking this box serves as my electronic signature confirming my consent. Privacy Policy: https://docs.google.com/document/d/1c4VrrQMgrfuaLhLqT6he_YNmmideNxebbuX7lU4Y_tM/edit?usp=sharing Terms & Conditions: https://docs.google.com/document/d/18P5llgkKPSr4ou3y_tntv9boJPMh0VMAyEm22EY0380/edit?usp=sharing
*
Yes, I consent
Submit
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