The Gathering
Sensory Club & Apo Kardias Special Needs Adult Day Program Intake
Participant Information
Participant Name
First Name
Last Name
Date of Birth of Participant:
-
Month
-
Day
Year
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Participant Email
example@example.com
Participant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Diagnosis/Medical Conditions
Guardian/Caregiver Name
First Name
Last Name
Guardian/Caregiver Address (if not at same address as participant)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian/Caregiver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian/Caregiver Email address
example@example.com
Relationship to Participant
Emergency Contact Name
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Referral & Background Information
Who referred the participant to the program?
Guardian/Caregiver
School
Physician
Social Worker
Case Manager
Other
If selected other, please provide name and designation:
Please provide Level of Need if known from HCS:
LON 1
LON 5
LON 6
LON 8
LON 9
Other
If selected other, please provide additional information :
Reason for seeking services:
Previous or current services received:
Occupational therapy
Physical therapy
Speech therapy
ABA therapy
Counseling
Vocational Training
Other
Please list current or previous providers/contacts (if applicable):
Rows
Name
Organization
Phone
Email
BCBA
Occupational Therapist
Speech Therapist
Physical Therapist
Case Manager
Other
Please provide copies of most recent IEP/ARD, Behavior Plan (BIP), psychological evaluation, or therapy evaluation/reports if available:
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Communication
Primary Communication Method:
Verbal
AAC device
Gestures
Sign language
Picture Exchange
Other
Communication Strengths:
Communication Challenges:
Can Participant independently communicate wants/needs?
yes
no
sometimes
Medical Information
Primary Physician & number:
Allergies:
none reported
food allergies
medication allergies
environmental allergies
Other
If Other was selected, please provide additional information:
Seizure History:
yes
no
If yes, please describe protocol and triggers:
Mobility Status
Independent
Require Supervision
Walker
Wheelchair
Other
If Other was selected, please provide additional information:
Toileting Support
Independent
Needs assistance for wiping/washing
Needs assistance for transferring/mobility
Needs assistance for clothing manipulation
Other
If Other was selected, please provide additional information:
Sensory Concerns
Noise sensitivity
Tactile Sensitivity
Sensory Seeking
Oral Seeking
Movement Seeking
Other
If Other was selected, please provide additional information:
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Behavioral & Safety Information
Does the participant demonstrate any of the following?
Elopement/Wandering
Aggression
Self-Injurious Behaviors
Throwing Objects
Verbal Outbursts
Difficulty with Transitions
Impulsiveness
Other
Known Triggers:
Successful calming/regulation strategies:
Safety concerns or precautions:
Family/participant goals for participation for within the program:
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