Parent Intake Form

Birthdate

Child's Age *

Diagnosis *

Parent/Guardian Name(s): *

Phone number

Physical Needs

Check as many boxes that apply.

Vision *

Typical

Impaired

Blind

Other

Hearing *

Typical

Impaired

Deaf

Hearing Aid

Other

Motor Function *

Head Control

Rolls Over

Sits

Crawls

Cruises

Walks

Walker

Crutches

Braces

Wheelchair

Other

Toileting Skills *

Toilets independently

Needs assistance

Wears a diaper

Being potty trained

Other

Eating Habits *

No restrictions

Nothing by mouth

Soft foods only

Bottle

Other

Will your child wear noise reducing headphones? *

Yes

No

Feeding Instructions or Tips:

Please list all allergies, including food allergies and restrictions:

Does your child have a history of seizures? If so, please explain below.

Communication

Check all that apply.

Your child's communication: *

Check all that apply.

Communication

Verbal

Limited Verbal

Nonverbal (no communication device)

Nonverbal (uses a communication device)

Other

Can understand what others say: *

All of the time

Most of the time

Some of the time

My child responds to separation from parents by: *

My child is best comforted by: *

My child lets someone know they need: *

Activities

Activities my child likes: *

My child needs encouragement to: *

My child does not enjoy: *

Please do not ask my child to: *

My child learns best when: *

My child participates more when: *

Behavior

Please check all that apply.

Describe your child's behavior: *

Outgoing

Shy

Plays in groups

Adapts to new situations well

Adapts to new situations with difficulty

Responds to corrections well

Responds to corrections with difficulty

Is sometimes destructive

Sometimes threatens others

Sometimes hits, bites, or hurts self/others

Sometimes attempts to run away

Hyperactive and/or ADD

ODD

Other