Client Intake & Service Agreement Form

L.E.X.I.S. Parent Intake & Service Agreement

Estimated completion time: 10–15 minutes. We’re here to support your family through a compassionate, inclusive intake process.

Parent / Guardian Information

Please share the details of the parent or guardian completing this form.
Relationship to Client (optional)
Parent / Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact

Other
Secondary Parent / Guardian Information

Complete this section only if a second parent or guardian should be included.
Secondary Parent / Guardian Name (optional)

First NameMiddle NameLast Name
Secondary Relationship to Client
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Email Address (optional)
example@example.com

Client Information

Please share information about the client receiving services.
Client Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Diagnosis
Brief summary
School or Program Attending (optional)
School, program, or daycare

Behavioural & Sensory Profile

Help us understand communication, sensory needs, and support strategies.
Communication Style
Sensory Triggers (optional)

Other
Calming Strategies
Short and specific
Support Needs
Brief details

Emergency Contacts

Primary and secondary contacts for urgent communication.
Primary Emergency Contact Name

First NameMiddle NameLast Name
Primary Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency Contact Relationship
Secondary Emergency Contact Name (optional)

First NameMiddle NameLast Name
Secondary Emergency Contact Phone (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact Relationship (optional)

L.E.X.I.S. Parent Intake & Service Agreement