Intake Form

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home to Name

First Name

Middle Name

Last Name

Languages

Primary Languages

Secondary Languages

Name Client goes by

Date of Birth

Gender

Home Address

Address Line 1

City

State

Zip Code

Family Information

Client lives with

Parent/Guardian 1

Name

Relationship

Address

Address Line 1

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Insurance Type

Date of Most Current Diagnostic Assessment

**Please complete the Release of Consent Form for the diagnostic assessment provider so that the center can obtain a current copy of the assessment upon enrollment. **

Strengths

Please list all of your child strengths such as drawing, writing, computer, etc.

Main Concerns

Please list any concerns the child may have at home or in the community. This may include, but not limited to, sensitivity (i.e. oversensitive to noises, oversensitive to certain material or texture of food), behaviors, communication, social skills and play skills. Additionally, provide any special accommodation that would help staffs to better support the child’s progress.