Parent Intake & Family Support Form
Please complete this form to help us understand your family's needs and how we can best support your child.
Parent / Guardian Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City of Residence
*
Preferred Method of Contact
*
Phone
Text
Email
Child’s Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
School Currently Attending
Grade Level
Has your child been diagnosed with any of the following?
Autism Spectrum Disorder
Developmental Delay
Speech Delay
ADHD
Sensory Processing Differences
Behavioral Challenges
Other
Other diagnosis (please specify)
Please describe your child’s strengths and areas where they need support
Is your child connected to a Regional Center?
*
Yes
No
In the process
Regional Center Name
Service Coordinator
Does your child have an Individual Program Plan (IPP)?
*
Yes
No
In Progress
Are you currently enrolled in the Self-Determination Program (SDP)?
*
Yes
No
Interested in learning more
Does your child have an Individualized Education Program (IEP)?
*
Yes
No
Currently being evaluated
School services currently provided
Speech Therapy
Occupational Therapy
Behavioral Support
Specialized Academic Instruction
Other
Other school services (please specify)
What type of support are you seeking?
Family Navigation / Advocacy
Help understanding Regional Center services
IEP preparation support
Enrichment programs
Social development programs
Movement / motor development activities
Community participation opportunities
Other
Other needs (please describe)
Allergies or medical conditions
Safety considerations
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent / Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: