Intake Reason

New Family

Update Family Profile

Phone *

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Today's Date *

MM

DD

YYYY

Name of Applicant *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Vision *

Glasses

Contacts

Vision not affected

Seizures *

None

Controlled

Uncontrolled

Respiratory Problems *

None

Asthma

Other

Heart Problems *

No

Yes

Need one-on-one assistance *

No

Yes

This applicant communicates in the following ways *

Talks in sentences and is easy to understand

Talks in sentences but may be hard to understand

Says words

Non-verbal but vocalizes

Uses a communication board

Uses a computer-assisted device

Nonverbal

Other

Hearing Problems *

None

Uses a hearing aid

Uses Sign Language

Cochlear Implant

Other

Following Directions *

Has no difficulty following directions

Is unable to follow directions

Follows simple one-step directions

Follows two-step directions

Other

Does the applicant read? *

Yes

No

Does the applicant write? *

Yes

No

Mobility *

Walks independently

Uses a wheelchair

Uses braces

Falls on occasion

Other

Food Allergies *

No

Yes

Special Food Issues *

None

Liquid diet

Soft food diet

Other

Difficulty Swallowing *

No

Yes

Food needs to be cut up

Tendency to choke

NPO (Nothing by mouth)

Toileting *

Independent

Wears diapers/pull ups

Typically has accidents

Requires assistance

Other

Behavioral Tendencies *

Temper tantrums

Running away

Yelling

Biting

Hitting

Refuses to follow directions

Aggression

Aversion to touch

Self harm

Refuses to speak

Not applicable*

Other