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PRIVACY FIRST We're taking extra measures to ensure your children's privacy. Learn More

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Intake Form

Please fill out the intake form and we will get back to you

Intake Questionnaire

Child Name

Date of Birth

Sex

Male

Female

Has your child received any formal diagnosis?

Yes

Diagnosis Date (Approximate If no exact date known)

Any Allergies?

Yes

Please list diagnosis result/special diet/allergies.

Current School

Grade

IEP?

Yes

Don't Know

What is your child’s main method of communication (i.e., sign language, gestures, pictures, verbalizations – if so, how many word phrases)? Briefly describe how he/she gets his/her needs met.

Does your child have any negative behaviors that you are concerned about (aggression, tantrums, non-compliance)? Please describe.

List some of your child’s likes:

List some of your child’s dislikes:

Goals

Fill in only the applicable categories. Be as specific as possible.

a) Language/Communication Goals:

b) Behavior Reduction:

c) Academic:

d) Self-Help:

e) Play/Leisure Skills:

f) Social Skills:

g) Gross Motor:

h) Fine Motor:

Other: Use this section to write in any additional information that you want us to know

Parent's Information

Parent/Guardian's Name

Phone

Program of Interest

Home Based Therapies

Centre Based Therapies

Virtual Therapies

Best method of communication

Phone

Best method of communication

Weekdays Between (9 AM to 12 PM)

Weekdays Between (12 PM to 3 PM)

Weekdays Between (3 PM to 6 PM)

Weekend

At our therapy center, we understand the value of your privacy. We want to assure you that all the information you provide in the intake form will be kept confidential and secure. We have strict measures in place to protect your data, and we will not use it for any marketing purposes.

Thanks for submitting the Intake form. We will get back to you!

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