Clone of New Driver Intake

NEW DRIVER ADAPTIVE INTAKE FORM

Physical Disability
Our program is a specialized investment in the safety, confidence, and long-term independence of each new driver. We provide individualized instruction for clients who experience physical challenges or barriers to driving that are not typically addressed by traditional driving schools. Traditional driving schools are NOT EQUIPPED or TRAINED to work with this cleintele.

We are the only driving school in Iowa that provides this level of specialized driver education and support. All instructors receive advanced training, and instructional vehicles are equipped with safety-enhancing equipment.

Every driver is unique. We do not compare clients, and there is no guarantee of licensure.

Honest and complete responses are essential. The information you provide allows us to design the safest and most effective instructional plan possible.
Form Element: Checkbox (Required – must select all)
SECTION 1 — CLIENT INFORMATION (REQUIRED UNLESS NOTED)
Client Age Category*
Client Legal First Name*
Client Legal Middle Name*
Client Legal Last Name*
Client Preferred NickName
Date of Birth *

MonthDayYear
Date
Gender*
Height*
Weight*
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client Email*
example@example.com
Parent/Guardian #1*

First NameLast Name
Parent #1 Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent #1 Email*
example@example.com
Address of Client*

Address

Street Address Line 2

CityState

Zip
Emergency Contact*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email*
example@example.com
This form must be completed electronically. THIS IS A CONFIDENTIAL FORM between you and the Driver Rehabilitation Professional.
In High School? Yes No (circle one) If yes, what was last grade completed*
Last Grade completed*
If graduated, Type NA
Name of School?*
If graduated, Type Graduate
City/State*
Does the Student have an IEP or 504 plan?*
FAMILY
1. Do you have any brothers/sisters/ages?*
2. Do you have any brothers or sisters that drive?*
3. Do you enjoy riding with them?*
4. What kind of vehicle do your parents drive?*
Select only one
5. What would you use a driver license for?*
6. What makes a driver’s license important?*
7. Do you think you can follow all the rules associated with driving a vehicle?*
8. If it takes 3-6 months to learn to drive, are you ok with that?*
9. Do you understand that there may be several driving restrictions if you get license?*
10. Do you understand that there is no guarantee you will get a driver’s license?*
11. Driving takes a lot of instruction and practice. Are willing to do this?*
12. Do you want to be a safe and responsible driver?*
13. What are your fears about driving?*
PERSONAL ABILITIES/APTITUDES/INTERESTS:
14. What skills are you good at?*
15. Do you like to observe or do things hands on?*
17. What makes you frustrated or upset?*
18. What worries or concerns you?*
19. What would your family/friends says is your most likable trait?*
20. What are your hobbies/favorite things to do?*
21. Do you listen to music?*
22. Who do you listen to or what style?*
Type NA if you do not listen to music
23. Do you watch TV?*
24. TV Shows watched*
Type NA if you do not watch TV
25. Do you play video games? If so, what?*
26. Games played?*
Type NA if you do not play
27. Do you play video games on your phone? If so, what?*
28. Games on your phone played*
Type NA if you do not play games on your phone
29. What things do you get excited about?*
30. Are there any things that you would like your driving instructor to know about you that can help them be a better teacher for you?*
This form must be completed electronically. THIS IS A CONFIDENTIAL FORM between you and the Driver Rehabilitation Professional.
Medical Information
Do you wear glasses?*
Do. you wear contacts?*
Are you hard of hearing or deaf?*
Do you use a Wheelchair, Crutches or another ambulatory device to walk?
Physician Full Name*

First NameLast Name
Medical Clinic/Facility*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Contact for Medical Records*
Diagnosis - Explain briefly if the situation, born with a condition, result of an injury, how long and what is expectation in the future if known.*
Medications - Please list name, dosage and frequency*
SECTION 2 — PERMIT / LICENSE INFORMATION
YesNo
If so, Please enter your Instructional Permit Number here. *
Type NA if no permit
Please state the Issue date and expiration date

MonthDayYear
Date
Please state the Expiration date

MonthDayYear
Date
YesNo
If so, Please enter your Driver's License Number here. Please include dashes, Issue date and expiration date*
Type NA if no License yet
Should be Empty:

NEW DRIVER ADAPTIVE INTAKE FORM

Form Element: Checkbox (Required – must select all)

SECTION 1 — CLIENT INFORMATION (REQUIRED UNLESS NOTED)

FAMILY

Medical Information

SECTION 2 — PERMIT / LICENSE INFORMATION