Teacher Intake Form - Community Services Intake (Updated 2022)

As part of the intake process for Estelle Siebens Community Services centre, Foothills Academy requests parents complete a parent intake form, then request their child's teacher to complete a Teacher Intake Form.

This form is for Amicus Camps & Recreation internal use only. The information provided on this form is used by our Community Services intake team to help make informed decisions when determining fit for Amicus Programs.

Our Amicus Camps & Recreation programs follow a mandate as outlined by the Community Services' intake criteria.

Our intake criteria is:

Primary diagnosis of ADHD and/or Specific Learning Disorder in reading, writing, math
Average to above average FSIQ
Able to function independently in a 3 child to 1 staff member ratio

This form is not accessible or used in any capacity by the Foothills Academy School Program.

If you have any questions or concerns about this form and its use, please contact our Intake Coordinator, Jana Stevenson, at intake@foothillsacademy.org

Date*

Date

Child's Name*

First NameLast Name

School Name*

Child's Grade*

Is this child in a specialized classroom setting or have an aide? Please give detail.

If funding was available, would you recommend an aide for this student? If so, what percentage of the school day would this student benefit from 1:1 support?

Please rate this child in the following areas by checking the box that best describes them. Please leave blank if you have insufficient information.*

	Severe issue	Moderate issue	Minor issue	No issue
Easily frustrated
Does not listen to direction from adults
Defiant/gets into power struggles
Physically hurts others when frustrated
Physically hurts self when frustrated
Verbal outbursts when frustrated
Mood changes quickly/drastically
Difficulty with transitions
Sensory sensitivity (e.g. noise)
Resists trying new things
Short attention span
Impulsive behaviour
Tendency to cry easily
Runs away or hides when stressed
Rigid thinking (inability to see another's viewpoint)

1. Please comment on any items you indicated in the chart above as a 'Severe' or 'Moderate Issue'. We're particularly interested in: specific triggers, how often it occurs, in which circumstances, and how it is managed within the school environment. Please provide as much detail as possible. If further follow up is needed as to the challenges indicated, our intake coordinator will reach out with parent/guardian consent.*

2. Please describe how this child interacts with other children within the school environment.*

3. In our programs, the child needs to be able to function independently enough that he or she does not require one-on-one assistance. We have a 3:1 counselor to child ratio but frequently they participate in group activities that could involve 12 children in our social skills programs or 30-36 children (55-60 including adults) in our camp programs. Do you think this child would have any difficulties?*

Any other comments:

Your name (Teacher)

First NameLast Name

Your email address (in case we have any follow-up questions)

example@example.com

Thank you for completing our questions. We truly appreciate your time.

Community Services Intake Process: Teacher Intake form