Community Services Intake Process

Intake Process - Teacher Intake Form

For all programs offered through Foothills Academy Community Services including: Amicus Camp/Recreation, Let's Be Social, Acting Social, Girls Only, Survive & Thrive in Junior High.
Our programs focus on explicitly teaching social skills, developing self-confidence and self-esteem.

In order to help us determine whether the program is a good match for the needs of this child, we would appreciate your perspective. While there are many children who struggle socially, our program has a specific mandate.

Our intake criteria are:
- Learning Disability (average to above average IQ) and/or ADHD
- No major behaviour or emotional regulation issues.
Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
School Name*
Child's Grade*
Is this child in a specialized classroom setting or have an aide? Please give detail.
If funding was available, would you recommend an aide for this student? If so, what percentage of the school day would this student benefit from 1:1 support?

Please rate this child in the following areas by checking the box that best describes them. Please leave blank if you have insufficient information.*

	Severe issue	Moderate issue	Minor issue	No issue
Easily frustrated
Does not listen to direction from adults
Defiant/gets into power struggles
Physically hurts others when frustrated
Physically hurts self when frustrated
Verbal outbursts when frustrated
Mood changes quickly/drastically
Difficulty with transitions
Sensory sensitivity (e.g. noise)
Resists trying new things
Short attention span
Impulsive behaviour
Tendency to cry easily
Runs away or hides when stressed
Rigid thinking (inability to see another's viewpoint)

1. Please comment on any items you indicated in the chart above as a 'Severe' or 'Moderate Issue'. We're particularly interested in: specific triggers, how often it occurs, in which circumstances, and how it is managed within the school environment.*
2. Please describe how this child interacts with other children within the school environment.*
3. In our programs, the child needs to be able to function independently enough that he or she does not require one-on-one assistance. We have a 3:1 counselor to child ratio but frequently they participate in group activities that could involve 12 children in our social skills programs or 30-36 children (55-60 including adults) in our camp programs. Do you think this child would have any difficulties?*
Any other comments:
Your name (Teacher)

First NameLast Name
Your email address (in case we have any follow-up questions)
example@example.com
Thank you for completing our questions. We truly appreciate your time.
Should be Empty:

Intake Process - Teacher Intake Form