SWS Client Intake

SWS Client Intake
Thank you for your interest in our services. In order to provide you with an estimate and/or schedule hearing and vision screenings please complete this form. Please fill out one intake form per school.

If you have any questions please email screening_coordinator@k12health.com

We look forward to hearing from you!
Contact Name:*

First NameLast Name
Contact Email:*
example@example.com
Contact Phone Number:*
Please enter a valid phone number.
Will you be the contact person on-site?*

YesNo
On-Site Contact Name:*

First NameLast Name
On-Site Contact Phone #:*
Please enter a valid phone number.
On-Site Contact Email:*
example@example.com

School Name:*
School Address:*

Street Address

Street Address Line 2

CityState / Province

City / Zip Code
Date of First Day of School:*
Date of Last Day of School:*
School Start Time:*
School Dismissal Time:*
Does your school have an early dismissal day or late start day?*

Early dismissalLate startNo
Early Dismissal/Late Start Day of the Week:*
Early Dismissal/Late Start Time:*
Please provide any necessary parking information for your school:*
Enrollment Data:

Please enter the estimated number of enrolled students in each grade. NOTE: If inaccurate data is provided in the fields below it may affect our ability to schedule your school. If you do not have students in one or more of the grades simply enter "0".
TK:*
Kindergarten:*
1st Grade:*
2nd Grade:*
5th Grade:*
8th Grade:*
10th Grade:*
IEP students in grades (3, 4, 6, 7, 9, 11, 12) that need screening:*
Are the above totals accurate for the 24-25 school year or will you need to provide updated numbers when the school year begins?*

Totals are accurate (+/- 5 students)Will update totals in Fall
Does your school participate in the Medi-Cal LEA Billing Option Program?*
Additional Comments:
Should be Empty:

Enrollment Data: