• Intake Form

    The following is to be completed by the child’s parent or legal guardian. This form has been designed to provide essential information before your initial appointment. Please feel free to add any additional information, which you think, may be helpful in understanding your child. Child Enrichment Center will hold information provided by you is strictly confidential and will only be released in accordance with HIPPA guidelines and as mandated by law. 
  • IDENTIFYING INFORMATION

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  • PARENT/GUARDIAN AND FAMILY INFORMATION

     

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  • Child Enrichment Center Schedule

    Treatment Session Times
  • INSURANCE INFORMATION

  • SECONDARY INSURANCE

  • PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD(S)

  • MEDICAL HISTORY AND HEALTH INFORMATION

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  • CURRENT SCHOOL PLACEMENT


  • COMMUNICATION SKILLS

    How does your child communicate or tell you what he/she wants?


  • Self-Care Skills

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  • Play Skills

  • Learning Skills

  • Challenging/Problem Behaviors



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  • Consent to Provide Intake

    This section is an agreement between Child Enrichment Center and the person and/or client completing this form, that once the Initial Intake meeting has been scheduled, that the client consents to provide the Initial Intake as specified below.
  • Services proposed during the Initial Intake: 

    All intake paperwork and observation of the client with their caregiver to which information derived from interviews and observations will be used to develop any of the following: 

    • Functional Behavior Assessment (FBA);
    • Behavior Change Plan or Behavior Intervention Plan (BIP);
    • Initial Treatment Plan or Skills Aquisition Plan.

    Benefits and risks of proposed services:  

    • Benefits - Services may lead to reduction of problematic symptoms.
    • Risks - Symptoms may worsen before improving or may not improve at all. 
    • Alternatives - No service of the use of other types of services. 
    • Anticipated results - Services will improve the possibility of positive outcome after treatment. 
  • For person(s) providing consent for Child Enrichment Center to provide an Initial Intake with the client:

    • I hereby consent to the Initial Intake meeting. 
    • I understand that I am able to ask questions about the proposed services. 
    • I understand that I may with withdraw my consent at any time with written notice. 
    • I understand that the anticipated results of any of the proposed services are not guaranteed and are based on the clinician's recommendations. 
    • I understand that the client's records about the services received will be kept in hard copy and electronic (computerized) forms. 
    • I understand that records about my child's services may be audited and used for evaluation and research with full protection of confidentiality. 
    • I understand that the Initial Treatment Plan, FBA or BIP, derived from the Initial Intake meeting will go through an authorization process, copies will be given and reviewed with the parent/caregiver during or prior to the first parent meeting in preparation to begin services. 
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  • COVID - 19 Protocol
    Child Enrichment Center follows the CDC protocol for cleaning and disinfection of surfaces, toys, and learning materials. For more information, https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html. In addition, we follow the Washington State guidance resource for businesses and employers found at https://coronavirus.wa.gov/information-for/business. We do not require our employees to provide medical information as that information should remain private according to HIPAA laws. Child Enrichment Center does not participate in COVID-19 contact tracing as this is not part of the Washington State guidelines for responding to COVID-19 in businesses and facilities. Staff and clients who have symptoms of illness should stay home and seek medical advice from their primary care physician (PCP). We no longer require temperature checks for staff and clients. If you would like further explanation, contact our office manager or owner at office@childenrichmentcenter.org.

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