Client Intake Form
CKFTO ID Number:
Child's Name:
Date:
-
Month
-
Day
Year
Date
Date of Birth (dd/mm/year):
-
Month
-
Day
Year
Date
Age:
Gender:
Female
Male
Parent/Caregiver Names:
Address:
Telephone:
Format: (000) 000-0000.
(Cell)
Format: (000) 000-0000.
E-mail:
example@example.com
School:
Class/Grade:
Any Known Allergies:
Diagnosis:
Unknown
Known Diagnosis (already assessed by a professional*)
Check all that apply:
Check all that apply:
Autism
Seizures/Epilepsy
Brain (Head) Injury
Hand Injury/Deformity
ADHD/Attention Issues
Motor Planning Issues
Cerebral Palsy
Down Syndrome
Hypotonia
Handwriting Problems
Swallowing / Feeding Issues
Behaviour Problems
Pervasive Developmental Disorder
Global Developmental Delay
Cognitive/Intellectual Disability
Speech/Language Disorder
Learning Challenges or Disabilities
Other
*Please bring all medical reports and assessments when you come for your scheduled appointment
Referred By:
Self
Professional
School
Friend
Media (Newspaper/Facebook/Website)
Other
Name of Referral Source (if Applicable):
Date of Referral:
-
Month
-
Day
Year
Date
Referral Letter Available:
Yes
No
Reason for Referral/What is your primary concern?
How long has this been an issue?
Referred For:
Occupational Therapy Assessment
PsychoEducational Evaluation
Speech Assessment
Physical Therapy
Specified CKFTO Service:
Occupational Therapy
Alert Program
Sensational Kid!
IEP
Physical Therapy
Lime! Program
Writing Sensation
HOPE Support
Zone Program
Speech & Language Therapy
SIBS
Therapeutic Listening
Communication Connection
CME Daily Program
19 Vidale Street St. James Trinidad and Tobago W.I. | Tel: (868) 628-3268 | Email: info@ckfto.org
CR01 Rev21/16
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Funding Source:
Self
Gov't Agency
NGO
Other 3rd Party
Insurance:
Yes
No
Name of Insurance Company
Financial Assistance:
Parent Informed of FAF
Yes
No
Date:
-
Month
-
Day
Year
Date
Parent given FAF
Yes
No
Date:
-
Month
-
Day
Year
Date
FAF
Accepted
Denied
Date:
-
Month
-
Day
Year
Date
Delivery Method:
By Hand
By Mail
FAF Returned to CKFTO
Yes
No
Date:
-
Month
-
Day
Year
Date
FAF Given to GM
Yes
No
Date:
-
Month
-
Day
Year
Date
Scheduling Information: Evaluation Date/Time:
Type of Evaluation:
Occupational Therapy
Psychoeducational
Name of Therapist:
Intake Information Received By :
Date:
-
Month
-
Day
Year
Date
Date of Return Call to Client:
Person Receiving Call:
Additional Issues or Comments:
19 Vidale Street St. James Trinidad and Tobago W.I. | Tel: (868) 628-3268 | Email: info@ckfto.org
CR01 Rev21/16
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