Family Intake Form
Child Information
Child's name
*
First name
Last name
Birth date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Prefer Not To Answer
Female
Male
Non-binary
Other
Current address
Street address
Street line 2
City
State / Province
Postal / Zip Code
Child resides with
Parent 1 only
Parent 2 only
Both parents in same household
Parent 1 and parent 2 in separate households
Guardian(s)
Other
Optional description or explanation
Household and Family Information
Parent/guardian 1
*
First name
Last name
Phone number
*
Email
*
Relationship to child
Profession or employment
Parent/guardian address - same as child?
Yes
Parent/guardian address (if different from child's)
Street address
Street line 2
City
State / Province
Postal / Zip Code
Parent/guardian 2
First name
Last name
Phone number
Email
Relationship to child
Profession or employment
Parent/guardian address (if different from child's)
Street address
Street line 2
City
State / Province
Postal / Zip Code
Siblings (names and ages)
Other members of household (name and relationship)
Back
Next
Parent/guardian address - same as child?
Yes
School Information
Current or most recent school
*
Grade
*
Attended from
start date
to
end date.
Please list past schools and dates/grades attended (past 3 - 5 years) .
Providers and Services
Please describe your child's primary interests and activities. What does your child enjoy doing? What excites or motivates your child, in or out of school?
Child currently receives the following supports:
Psychotherapy/counseling
Psychiatry
Occupational therapy
Tutoring
School-based academic support
School-based social/emotional support
Other
Other: please explain
Child has or had (current or past) the following:
Psycho-educational evaluation
Mental health diagnosis
Physical disability diagnosis
Developmental disability diagnosis
IEP or 504 plan
Other
If other, please specify.
Document Submission
In this section, please submit any documentation that will help us understand your child's academic profile or performance and social/emotional health.
Do you have documents to upload?
*
Yes
No
Document type
Please Select
Report card/transcript
Evaluation
IEP
504
Provider notes
Other
Document title or description
File Upload
Browse Files
Drag and drop files here
Choose a file
You may upload multiple documents of the same type (i.e. two psycho-educational evals). Please upload different document types using the fields below.
Cancel
of
Do you have additional documents to upload?
*
Yes
No
Document type
Please Select
Report card/transcript
Evaluation
IEP
504
Provider notes
Other
If other, provide type of document.
File Upload
Browse Files
Drag and drop files here
Choose a file
You may upload multiple documents of the same type (i.e. multiple psycho-educational evaluations). Please upload different document types using the fields below.
Cancel
of
Do you have additional documents to upload?
*
Yes
No
Document type
Please Select
Report card/transcript
Evaluation
IEP
504
Provider notes
Other
If other, provide type of document.
File Upload
Browse Files
Drag and drop files here
Choose a file
You may upload multiple documents of the same type. Please upload different document types using the fields below.
Cancel
of
Do you have additional documents to upload?
*
Yes
No
Document type
Please Select
Report card/transcript
Evaluation
IEP
504
Provider notes
Other
If other, provide type of document.
File Upload
Browse Files
Drag and drop files here
Choose a file
You may upload multiple documents of the same type. Please upload different document types using the fields below.
Cancel
of
Do you have additional documents to upload?
*
Yes
No
Document type
Please Select
Report card/transcript
Evaluation
IEP
504
Provider notes
Other
If other, provide type of document.
File Upload
Browse Files
Drag and drop files here
Choose a file
You may upload multiple documents of the same type. Please upload different document types using the fields below.
Cancel
of
Do you have additional documents to upload?
*
Yes
No
Document type
Please Select
Report card/transcript
Evaluation
IEP
504
Provider notes
Other
If other, provide type of document.
File Upload - Please include all additional documents here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is there any other information you think is useful to share with us?
Submit
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