SJ's Friends Intake Inquiry Form
Please complete this intake inquiry form to request services for your child. A team member will follow up with you after submission.
PLEASE READ BEFORE COMPLETING INQUIRY FORM: I understand that SJS Friends is not a alternative to ABA (Behavioral Therapy) and that SJS Friends does not accept children with excessive violent behaviors, spitting or excessive destructive behaviors. SJS Friends is also not equipped to care for children who are tube fed and/ or with seizure disorders.
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I acknowledge this statement.
Parent/Guardian Full Name
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First Name
Last Name
Parent/Guardian Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
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example@example.com
Child's Full Name (please complete separate form if multiple children)
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First Name
Last Name
Child's Date of Birth
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Month
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Day
Year
Date
Services Needed (Select all that apply)
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Respite
Daily Living Skills
Mental Health Services
Transportation (Note: We only provide transportation to/from CLTS covered services)
Please tell me about your childs behaviors and individual needs. SJS Friends is not an alternative to ABA and we do not accept children with excessive violent behaviors, destructive behaviors or spitting. SJS Friends is devoted to being a safe place for all children at our program. We will refer you to programs that would be a better fit.
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Is your child potty trained? We are able to provide minimal potty assistance such as helping wipe or bathroom reminders. Our location does not have a full changing area therefore we are unable to accept children who are not potty trained.
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Yes, Fully Independent
Yes, Needs Help With Wiping/Reminders
No, My Child Is Not Potty Trained
Is your child enrolled in CLTS?
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Yes
No
Case Manager Name
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First Name
Last Name
Case Manager Email
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example@example.com
Case Manager Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
I authorize SJ's Friends to contact me after submission
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Yes
No
Submit Inquiry
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