Family Pre-Intake Questionnaire
Thank you for your interest in The Capstone Center. Your answers help our clinical team prepare for our first conversation and, if we move forward together, give us a head start on getting to know your child. Please answer as much as you're comfortable sharing.
Child's Information
Child's full name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Town and school district of residence
Does your child currently have an IEP?
*
Yes
No
In process
Not sure
Primary diagnosis (if any), and who made the diagnosis
Other diagnoses or medical conditions we should know about:
How does your child communicate today? (check all that apply)
Vocal speech
AAC device
Picture exchange (PECS)
Sign language
Gestures
Emerging communication
Caregiver Information
Parent/Guardian 1 Full Name
*
First Name
Middle Name
Last Name
Relationship to child:
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Resides with child?
Yes
No
Parent/Guardian 2 Full Name (if applicable)
First Name
Middle Name
Last Name
Relationship to child:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Resides with child?
Yes
No
Current Services and School Program
Please describe the type of services your child currently receives or the the school program they attend.
Your Goals for Your Child
What are three skills you would most like to see your child build?
Are there any behaviors you would like to see decrease?
What are some things your child enjoys the most? (favorite activities, toys, foods, people, places)
What are your child's strengths?
In what areas does your child most need support?
Safety and Medical Considerations
Are there any safety concerns we should be aware of? (for example: wandering or elopement, self-injury, aggression, pica)
Does your child have any allergies, dietary restrictions, seizure history, mobility needs, or medical needs during the school day (including nursing services)?
Placement and Funding
Intended funding source
School district placement
Insurance
Private pay
Not sure yet
Type of services you're interested in
Full-day school placement
Extended school year (summer)
Home program
Other
If other, please describe:
When are you hoping to start?
As soon as possible
This school year
Next school year
Just exploring
Additional Intake Questions
Is there anything else you'd like us to know about your child or your family's situation?
How were you referred to our Center?
Acknowledgements
*
I confirm the information provided is accurate to the best of my knowledge.
I understand I am responsible for any updates to my information.
I consent to being contacted regarding my intake information.
Submit
Should be Empty: