Exceptional Learner New Driver Intake

Exceptional Learner (under 18) New Driver Intake

Complete this intake form to help us design the safest, most effective instructional plan for your needs.
Acknowledgments and Client Information
Acknowledgments (required – please check all)
Client Age Category
Client Legal First Name
Client Legal Middle Name
Client Legal Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Height
Weight
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Parent/Guardian #1

First NameLast Name
Parent #1 Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent #1 Email
example@example.com
Address of Client

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Medical Information
This form must be completed electronically. THIS IS A CONFIDENTIAL FORM between you and the Driver Rehabilitation Professional.
Do you wear glasses?
Do you wear contacts?
Are you hard of hearing or deaf?
Do you have a diagnosis of Autism?
If so, please tell me when you were diagnosed and by who.
Do you have Anxiety?
Describe the best you can, what makes you anxious or what causes your anxiety.
Do you take meds for your anxiety? Please list what you take, dosage and how often.
Do you have a diagnosis of ADD or ADHD?
If you have ADD or ADHD, when were you diagnosed and do you take any meds? If so please list what you take, dosage and when.
Any other cognitive conditions or executive functioning disorders that affect your life on a daily basis? If so, please list.
Have you ever had a concussion?
If so, when?
Have you had more than one concussion?
Have you ever had a seizure?
If so, when was your last one?
Do you take medication to prevent seizures?
Physician Full Name

First NameLast Name
Medical Clinic/Facility
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
MEDICAL RELEASE FORM
This is a medical release of information authorization which allows Heartland Mobility and Driving for Exceptional Learners to be in contact with your Medical Professional(s). We will contact the Medical Professional in the event we require additional perspective on the proposed driver's ability to drive. This is necessary for us to best understand your driving needs.
I, the undersigned, do authorize and request the below Individual/Agency to release to Safer Driver Solutions all medical records for the above patient/client.
Medical Clinic/Agency
Medical Clinic/Agency Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical Professional's Name

First NameLast Name
Medical Professional's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Professional's Email
example@example.com
Select all that apply
The information being disclosed may be used only for the following purposes. Select all that apply:
I acknowledge that I have carefully read this authorization in its entirety as completed, understand its contents, and have signed this authorization as my own free act. A photocopy or exact reproduction of this authorization shall have the same effect as the original. If this authorization is executed by a person other than the client, that person represents and declares that he/she is the legal representative of the client and has the authority to execute this authorization on behalf of him/her.
Consent to Use & Disclose Health Information: I acknowledge that the information to be released may include material that is protected by either state and/or federal law applicable to mental health information. My signature authorizes release of all information as specified above.
Print Name

First NameLast Name
Relationship to Client
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you receive medical care at University of Iowa Health Care (UIHC)?
University of Iowa Health Care requires its own release form before they will send records to us. Check the box below and we will email you the UIHC release form to complete.
UIHC Medical Release Request
School Information
In High School?
Last Grade Completed
Name of School
City/State
Are you home schooled?
What is your home School District?
Does or Did the Student Have an IEP or 504 Plan?
FAMILY
Do you have any brothers or sisters? If so, what are their ages?
Do you have any brothers or sisters who drive?
Do you enjoy riding with them?
What kind of vehicle do your parents drive?
What would you use a driver's license for?
What makes a driver's license important?
Do you think you can follow all the rules associated with driving a vehicle?
If it takes between 3–6 months to learn to drive, can you be patient with that?
Do you understand that there could be driving restrictions if you get a license?
Do you understand that there is no guarantee you will get a driver's license?
Driving takes a lot of instruction and practice. Are you willing to do this?
Do you want to be a safe and responsible driver?
What are your fears about driving?
PERSONAL ABILITIES/APTITUDES/INTERESTS
14. What skills are you good at?
15. Do you like to observe or do things hands on?
17. What makes you frustrated or upset?
18. What worries or concerns you?
19. What would your family/friends say is your most likable trait?
20. What are your hobbies/favorite things to do?
21. Do you listen to music?
22. Who do you listen to or what style?
23. Do you watch TV?
24. TV Shows watched
25. Do you play video games? If so, what?
26. Games played?
27. Do you play video games on your phone? If so, what?
28. Games on your phone played
29. What things do you get excited about?
30. Are there any things that you would like your driving instructor to know about you that can help them be a better teacher for you?
SECTION 2 — PERMIT / LICENSE INFORMATION
Have you had a DOT Medical Report (Iowa DOT Form 430031) filled out by your physician before your permit was issued?
If not, this DOT Medical Report must be completed by your physician before your permit can be issued, or before your driver's license can be issued if driving lessons are successful. Check the box below and we will email you the form to take to your physician.
DOT Medical Report Request
If you already have a completed DOT Medical Report, please upload a copy here.

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Do you currently have a learner's permit?
If yes, enter your instructional permit number.
Permit issue date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Permit expiration date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you currently hold a driver's license?
If yes, enter your driver's license number (example: 123XX4567).
Please upload the front and back of your driver's license, if available.

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Should be Empty:

Exceptional Learner (under 18) New Driver Intake

Acknowledgments and Client Information

Medical Information

MEDICAL RELEASE FORM

School Information

FAMILY

PERSONAL ABILITIES/APTITUDES/INTERESTS

SECTION 2 — PERMIT / LICENSE INFORMATION