InTake Form

First Name

Last Name

Primary Languages

Secondary Languages

Name Client goes by

Date of Birth

Gender

Home Address

City

State

Zip Code

Patient Lives With

Parent/Guardian Name

Relationship

Address

City

State

Phone

Email Address

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

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.

InTake Form

Quick Links

Contact Details