INTAKE FORM

Thank you for your interest in Level Up Social Communication Therapy. Please complete this form to begin the intake process.

After reviewing your submission, I will contact you within 48 hours to schedule an intake session where we can discuss your child's strengths, areas of need, and determine if my services are a good fit.

You can also learn more about my approach here: www.leveluptherapynaperville.com. I look forward to meeting you and your child!

Student Name

First NameLast Name

Date of Birth

Date

Age/Grade

Parent/Guardian Email

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about Level Up Social Communication Therapy?

Has your child previously received school-based or private speech therapy for social communication?

If you answered yes to the above question, please describe the services your child has received or is currently receiving to address social communication (i.e., setting, duration, goal areas).

Please rate your child's current skills using the ratings provided.

Rows	Consistently	Often	Sometimes	Rarely/Not Yet
Initiates conversations with peers
Maintains back-and-forth conversations
Pays attention to others' experiences/interest
Understands unspoken social rules
Adjusts communication style to fit the setting
Reads social cues (tone, facial expression, body language)
Advocates for self (asks for help when needed)
Socializes outside of school
Accepts feedback about social behaviors

Which social communication, perspective-taking, or real-world interaction skills would you most like your child to develop at this time?

Sessions typically begin as 1:1 therapy and may transition to small group and/or community-based sessions as appropriate to support skill generalization. What is your preferred session frequency?

Level Up Social Communication Therapy is a private-pay practice. I do not bill insurance directly. Payment is due at the time of service via cash, Zelle, or credit card. Receipts may be provided upon request.

Some therapy sessions may take place in community settings (e.g.., restaurants, coffee shops, stores, or other public locations) to support generalization of skills.

Community-based sessions are designed for teenagers and young adults who are working to build social connections and confidence in real-world settings. Participants in these sessions are expected to engage in group activities with minimal behavioral intervention and follow basic safety expectations.

If a student requires additional support, services may begin in a 1:1 setting to build foundational skills and readiness for group or community-based work. Referrals may be provided when appropriate.

By proceeding, you acknowledge:

Community-based sessions involve natural, real-world environments
Your child is expected to follow safety and participation expectations
Level Up Social Communication Therapy is not responsible for events outside of reasonable supervision.

Please indicate understanding by checking the box below.

Is there anything else you would like me to know about your child?

Parent/Guardian Name:

Today's Date:

Date

Signature

Please indicate understanding by checking the box below.