School Support Program Connections Services Intake Form

School Support Program Connections Services Intake Form
Consent for Intake
Please select appropriate boxes :
Clinician/Board Staff/ Teaching Staff
Parent/Guardian

Family & Student Information
Student Information:
Student Name
Student Date of Birth

MonthDayYear
Date
Caregiver 1 :
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Does the family require a translator for meetings?
If yes, please indicate language need:
Caregiver 2 :
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Does the family require a translator for meetings?
If yes, please indicate language need:

OAP Service Provider Information
Agency Name:
Name of Clinician:
Clinician Email:
example@example.com
When did your Core Service Start:

MonthDayYear
Date
When is your Core Service End Date

MonthDayYear
Date

School Information

For students attending school AND core service, please indicate school schedule:
Has the family registered for school?
Does the family need help with school registration?
School Board
School Name
Grade
Upon completion of intake, the Manager of SSP will determine service eligibility and an ASD Consultant will respond to your inquiry within 1 business week.
Should be Empty: