School Readiness Intake Form

Child's Name

First Name Last Name

Date of Birth

Date

Age

Pronouns:

she/her he/him they/them

Sex Assigned at Birth (required for insurance billing):

Parent's Name

First Name Last Name

Intake Completed By

First Name Last Name

Best Phone Number

Area Code Phone Number

Email *

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact

First Name Last Name

Emergency Contact Phone

Area Code Phone Number

How did you hear about our program?

Please list any previous diagnoses: *

Does your child have physical challenges? If yes, please describe:

Does your child have any attention or behavioral concerns in groups or with peers? If yes, please describe:

Has your child had any exposure to group settings (peer play, school, community, etc.)?

Describe your child's current language skills (length of sentences, how many step directions can he/she follow, does he/she answer questions, how easily can he/she be understood by peers):

Is your child potty trained? *

Describe your 3 main goals for this program: *

Does your child have any allergies or other important medical conditions? *

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

Yes No

Will you be requesting Rocky Mountain Human Services funding for this group? *

Yes No

I am interested in (Please note we are *WAITLIST ONLY* - June 13 through July 1): *

Summer 2022 - Full Semester • June 6-August 19 • Monday-Friday 9:00AM-11:45AM Summer 2022 - 2 week option (10 sessions); please indicate specific dates below Summer 2022 - Day to Day (Min 8 sessions); please indicate specific dates below *Summer 2022 Waitlist for July 18-29, 2022* Fall 2022 - Full Semester • October 3-December 3 • Mondays, Wednesdays, Fridays 9:00AM-11:45AM

Other Scheduling Requests (please include specific dates if not applying for the full semester):

By clicking submit, I agree to forfeiting the $150 deposit required for registration if we do not give at least 14 days notice of cancelation before the first day of the group.