STAR Institute Group Intake Form

STAR Institute Group Intake Form
Today's Date:

MonthDayYear
Completed by:*
Child's Name:*

First NameLast Name
Age:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth:

MonthDayYear
Identified Gender:

MFNon-binaryOther

Which Group(s) are you interested in? Please include Group name(s) and associated dates and times.*
Which Group(s) are you interested? Please select all groups and dates/times*

FALL/WINTER CAMPSArts and Crafts Nov 27th-Dec 20th (Monday and Wednesdays) 4pm-5pmI'm interested in SUMMER Camps please reach out to me with options. Summer camps registration will not open until 2024.
If you are interested in School Readiness, what dates would you like to register (2-week minimum registration is required)? Enter "0" if you are not applying for School Readiness.
Parent's Name:*

First NameLast Name
Primary Phone:*

Area CodePhone Number
Cell Phone:

Area CodePhone Number
E-mail*
Emergency Contact Name:
Emergency Contact Phone Number

Area CodePhone Number
List any known diagnoses and assistive/adaptive devices/equipment your child uses:
List any previous treatment at STAR Institute or other providers: (include any current or previous therapies and testing)
Please describe your concerns for your child in regards social, sensory, or functional challenges:
Your child's interests:
Please describe how your child plays and interacts with their peers:
Please describe your child's current language skills: (length of sentences, how many step directions can they follow, do they answer questions, how easily can they be understood by peers)
Does your child have any sensory sensitivities (ex: auditory, tactile, etc.?)
Does your child have physical challenges?
Does your child have any allergies or other important medical conditions?*
Will you be receiving funding assistance through Rocky Mountain Human Services?*

YesNo
Will you be receiving Developmental Pathways funding for this group?*

YesNo
Enter the message as it's shown*
How did you hear about this Group?
Each Group requires a deposit of $50 as well as an intake call completed with the Group Lead Therapist. Deposits and Intakes are required to secure your spot in a group. Deposits are due at time of acceptance to group (confirmed by email and/or phone call). Once the deposit is paid and the intake call is complete we will notify you of your secured spot.

Remainder of balance for a Group is due 1 week prior to your child's start in your chosen Group. Deposits are refundable up to 2 weeks before your chosen group starts. By clicking the "submit" button, you are acknowledging the requirement of a deposit to secure your spot and that deposits are refundable only up to 2 week before your Group starts.
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