Northeast Arc Recreation Community Partnership Intake Form
Participant Information
Community Partner
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Participant Name
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Age
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Gender Identity
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Diagnosis/and or nature of participant's needs
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Current picture of the participant
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Emergency Contacts
Emergency Contact #1 - Name
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Emergency Contact #1 - Relationship
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Emergency Contact #1 - Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 - Name
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Emergency Contact #2 - Relationship
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Emergency Contact #2 - Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Medical and Accessibility Information
Type of support participant typically receives
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Group/Social Support
1:1 Support
ADL/Medical/Full Assistance
Medical conditions staff should be aware of
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Is the participant subject to seizures
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Yes
No
If yes, please explain
Does the participant have any allergies
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Yes
No
If yes, please explain
Any dietary restrictions
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Yes
No
If yes, please explain
Does the participant utilize any assistive devices
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Yes
No
Assistive devices used
Wheelchair
Walker
Braces
Crutches
Cane
Does the participant have a visual impairment
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Yes
No
If yes, please explain
Does the participant have a hearing impairment
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Yes
No
If yes, please explain
Physical limitations that may impact participation (endurance, balance, low muscle tone, gait, etc.)
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Communication and Independence
Participant level of communication (Check all that apply)
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Verbally Independent
Speech Delay
Communication Aid
Sign Language
Does the participant verbally advocate for themselves (needs, wants, feelings)
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Yes
No
Is the participant able to follow directions
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Independently
With verbal prompting
With step-by-step assistance
What setting is most successful for the participant
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Structured
Unstructured
Both
Is the participant able to stay with a group
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Yes
No
Does the participant have a history of wandering
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Yes
No
Can the participant recognize danger
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Yes
No
Can the participant manage their own belongings
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Yes
No
Does the participant get frustrated by others easily
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Yes
No
Does the participant bolt unexpectedly
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Yes
No
Is the participant typically oppositional/defiant
Yes
No
Can the participant manage their own emotions
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Yes
No
Can the participant control their impulses
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Yes
No
Does the participant exhibit verbal outbursts
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Yes
No
Does the participant exhibit any physically aggressive behaviors
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Yes
No
If yes, towards self or others
Possible triggers for aggressive behavior
Warning signs of anxiety, frustration or behavior escalation
Socialization, Behavior, and Strengths
How does the participant socialize
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Initiates social interaction on their own
Socializes with prompting
Avoids social interactions
What setting is the participant most successful in
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Large groups
Small groups
Both
Does the participant have difficulty sharing or taking turns
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Yes
No
Does the participant maintain personal boundaries
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Yes
No
Does the participant understand social cues
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Yes
No
Behavior techniques used at home/school that work well
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What motivates the participant (e.g. rewards, praise)
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What are some interests / likes of the participant
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What are some dislikes or fears of the participant
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What are some of the participant's strengths
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Any additional information you would like to share
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