Online Intake Form

Online Intake Form

Support Services for Caregivers of Children with Autism and/or ADHD
Child´s information
Child´s full name

First NameLast Name
Date of birth

MonthDayYear
Date
Diagnosis (if applicable)
Parent or legal guardian information
Caregiver´s full name

First NameLast Name
What is your age?
Languages spoken at home:
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Prefered Method of Contact:

Phone CallEmailText message
Payment Information
Does your child currently have health insurance?

YesNoIn process
How would you pay for services?

Private payDDS fundsHealth InsuranceI don´t knowOther funds, grants or programs.
Interest in Respiro Azul Services
How often are you interested in receiving services?

Once a weekSeveral times a weekBiweeklyOcassionallyOther
Prefered times (Please check all that apply):

MorningAfternoonWeekendsOther
Do you have any medication allergies?

YesNoNot Sure
Do you use any kind of tobacco or have you ever used them?
Do you use any kind of illegal drugs or have you ever used them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Main needs or concerns you would like to share with us:
Current Supports
Does your child currently receive any of the following services? (check all that apply):

Applied Behavior Analysis (ABA)Occupational TherapySpeech TherapyPhysical TherapyIn-home support servicesSchool-based services (IEP, 504 Plan,etc.)Other
Do you currently work with any case manager, agency, or family support provider?

YesNo
Communication & Behavior
How does your child communicate?

VerballyUses gestures or sign languageUses a communication deviceUses PECS (Picture Exchange Communication System)Other
Please check any behaviors that apply:

Elopes or runs away from safe areasAgressive of self-injurious behaviorsHigh levels of anxiety or sensory sensitivityDifficulty interacting with peer or unfamiliar adultsOther
Safety & Emergency Information
Does your child have any of the following medical considerations?

Seizure disorderSevere allergiesMedication needs during care hoursOther
Does your child require one-on-one supervision?

YesNoNot sure
Has your child had any past incidents that required emergency medical attention?

YesNoNot sure
Availability for Intake Appointment (Virtual)
Comprehensive Intake Assessment & Authorization to Contact

Before beginning services, all families are required to participate in a Comprehensive Intake Assessment lasting approximately 45 to 60 minutes. This assessment allows us to better understand your child’s strengths, needs, and eligibility, and is required to formally initiate services.

This appointment will be billed either:
☐ To your health insurance (if eligible)
☐ As a self-pay session
☐ Through a collaborating organization (if applicable)
Appointment
I authorize Respiro Azul to contact me to coordinate this assessment and any necessary follow-up. This initial contact will not have cost.
Signature
Should be Empty:

Online Intake Form

Child´s information

Parent or legal guardian information

Payment Information

Interest in Respiro Azul Services

Current Supports

Communication & Behavior

Safety & Emergency Information

Availability for Intake Appointment (Virtual)