New Participant Intake Form

New Participant Intake Form

Please fill out this form to provide your basic information and medical history. Your privacy is important to us.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you filling out this form for yourself or someone else? Please list all contact information below that we will need so that we can stay in touch. ( Your name, email and phone would be great.)
Please describe any current diagnoses that will help us understand you better
List any allergies you have, including medications, foods, or environmental factors.
Provide details about any past surgeries or significant medical procedures.
Please list any chronic illnesses or ongoing health conditions.
Are you currently taking any medications? If yes, please list them below.
Have you experienced any recent hospitalizations or emergency room visits?
If yes, please let us know more about the dates, location and reason for admission.
Tell us a bit about what kind of services or supports you'd like to discuss:

Other
Did you complete high school?
What school or schools did you attend and when did you graduate ?
Did you complete college or are you in college now?
What school did you either attend or are currently enrolled in?
If you have information such as IEPs, professional evaluations or reports that will help us understand you better, please upload them here. They will be reviewed only by our Clinical Director and Clinical Team.

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In your own words, tell us about what a great day looks like for you and tell us how you'd like us to help. You can say something like, " I'm living with my parents but I'd like to live on my own." Then let us know what kinds of things you enjoy or want to work on. You could also say, " I live on my own but want to move and have more help." or " I am a parent and need some help with my adult child." Or perhaps you are an older adult and want some supports to keep your independence. We'd love to hear from you!
I'd like to schedule a follow-up call. The best days and times to reach me are:
Thank you for reaching out to heyChicago! and APlus Autism Solutions. We will let you know when we have reviewed your information and next steps via email.
Should be Empty:

New Participant Intake Form

Thank you for reaching out to heyChicago! and APlus Autism Solutions. We will let you know when we have reviewed your information and next steps via email.