CLIENT INTAKE FORM
Parent(s) or Guardian Name
*
Child's First and Last Name
*
Gender
*
Address
*
D.O.B
*
Postal Code
*
City
*
Province
*
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
*
Phone
*
Format: (000) 000-0000.
Physician
Phone
Format: (000) 000-0000.
Health Card No.
*
Please let us know which of the following services your child will be participating in:
*
1:1 services (Minimum 3 hours - Maximum 12 hours)
2:1 services (Minimum 3 hours - Maximum 12 hours)
Senior Respite Services (Minimum 3 hours -Maximum 12 hours)
Overnight Respite
Transportation
How many hours a week are you interested in?
*
Do you have a gender preference who is supporting your loved ones ?
*
Male
Female
Doesn't matter
How soon are you wanting to begin services ?
*
ASAP
Couple Weeks
In a month
Does your child require any personal care?
*
Yes
No
If Yes, please explain
Does your child require wheelchair accessibility?
*
Yes
No
Do you consent to planned field trips / Group day camps?
*
Yes
No
Does your child have a current (or past) diagnosis (physical, behavioral, developmental, mental)?
*
Yes
No
If Yes, please explain
Health Conditions: (Please include any additional physical, mental health or behavioral or developmental concerns)
*
Medications Prescribed and Time: (All Medication must be in original bottle or packaging with a doctor's note to administer)
*
Medical History
*
Are there any allergies that we need to be aware of?
*
Yes
No
If Yes, please explain,
Do you receive funding?
*
Yes
No
If yes, which funding do you receive?
Any additional Information/Comments
Do you consent take 5 respite services to transport your child in case of an emergency?
*
Yes
No
Do you consent to the use of photos of your loved one(s) to be used on Social media?
*
Yes
No
At take 5, we require families to sign a 6 or 12 month contract in order to keep a consistent schedule with clients and associates to maintain the highest quality of service. Please select below which contract you prefer.
*
6 month
12 month
Ongoing
How can we best care for your child?
*
How did you hear about take 5 respite services?
I consent that the information stated above is true to the best of my knowledge.
Signature
*
Date
*
/
Month
/
Day
Year
Date
Print
Continue
Continue
Thank you for allowing our take 5 family to take care of yours!
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