English Intake Form

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
Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Current Age
Gender

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Preferred Phone/Mobile Number *

Area Code Phone Number
Diagnosis *
Secondary Diagnosis
Date of Diagnosis *

Month Day Year
Date
Diagnosed by *
PARENT/GUARDIAN AND FAMILY INFORMATION
Mother or Caregiver's Name

First Name Last Name

Mother or Caregiver's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number *

Area Code Phone Number
Mobile Number

Area Code Phone Number
Email *
example@example.com
Occupation
Father or Caregiver's Name

First Name Last Name

Father or Caregiver's Address (if different)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Number

Area Code Phone Number
Email
example@example.com
Please List Siblings: Ages/Gender/Diagnosis
Other Person's Living at Home
Other Relevant Family Information
INSURANCE INFORMATION
Name of Insurance Carrier *
Name of Beneficiary or Sponsor (name of child or parents insurance is covered under) *
Date of birth of Beneficiary or Sponsor *
Member ID# *
Co-pay Amount *
Deductible Amout *
SECONDARY INSURANCE
Name of Secondary Insurance Carrier
Name of Beneficiary or Sponsor (name of child or parents insurance is covered under)
Date of birth of Beneficiary or Sponsor
Member ID#
PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD(S)
Front of Primary Insurance Card *
Back of Primary Insurance Card *
Front of Secondary Insurance Card
Back of Secondary Insurance Card
MEDICAL HISTORY AND HEALTH INFORMATION
Current Primary Care Physician (PCP) Name
Physician Phone Number

Area Code Phone Number

Physician's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Other Healthcare of Medical Provider Name(s):
Current Medications and Doses
Over the Counter Medications
Food/Drug Allergies
Has your child had a physical exam or well check in the past year?
Do we have consent to communicate with your child's physician?
If no, please provide a reason for refusal
Child's past or current history and/or treatment of: (please check all that apply)

Hospitalizations Thyroid Problems Digestive Disorder Meninggitis Surgeries High Fevers Migraines Urinary Tract Infections Seizures Head Injury Diabetes Ear, Nose, & Throat Problems Ear Infections Asthma Anemia Serious Illness
Family Members Medial History:

Seizures Asthma Stroke Cancer Migraines Chronic Pain Sleep Disorders Liver Damage Tuberculosis Diabetes Eating Disorder Heart Disease Kidney Disease Food Allergies Thyroid Problems Anemia Hypertension
Psychosocial History (Please check those diagnosis that anyone in the child's immediate family have)

Autism Spectrum Disorder Learning Disabilities ADHD-ADD Attention Problems Depression & Manic Depression Anxiety Disorder (OCD, Phobias...etc) Cognitive Impairment Psychosis/Schizophrenia
CURRENT SCHOOL PLACEMENT
Is your child currently attending school?

Yes No
Name of School
Placement (i.e. life-skills, resource room)
Current Grade Level
What days does your child attend school?

Monday Tuesday Wednesday Thursday Friday
School Schedule
COMMUNICATION SKILLS

How does your child communicate or tell you what he/she wants?
(Please check all that apply)

Verbal (one word) Verbal (short phrases) Verbal (sentences) Communicates frequently Communicates rarely Cries and whines Points or pulls adult to what is wanted Sign language Picture communication Does not try to communicate Tablet (Proloque) Needs prompting to communicate
If your child does not do any of the above ways to communicate what they want, does your child babble?

Yes No
How many words does your child uses consistently in his communication (approximate). Please provide examples.
Does your child label things in a book or on flashcards?

Yes No
If so, how many labels and please provide examples:
Can your child imitate words? (e.g., you say, "say ball" your child says "ball")

Yes No Sometimes
Self-Care Skills

Eating

Yes

Sometimes

Partial or with Help

Not Sure

Special Diet

Selectivity/Picky Eater

Eats at the table with family for meals

Eats using utensils

Drinks from an open cup

Drinks from a straw

Drinks from a sippy cup

Still drinks from a bottle

Eats pureed/baby food

Can your child sing songs or fill in the blanks to words in a song? (e.g., "twinkle, twinkle little ____.")

Yes No Sometimes
Can your child respond to their name when called?

Yes No Sometimes
Can your child answer questions? (e.g., what is your name? or how old are you?)

Yes No Sometimes
Can your label or touch body parts when told? (e.g., "touch your toes" child touch toes)

Yes No Sometimes
Can your child sit at a table or the floor and do simple tasks with an adult ?

Yes No Sometimes
Can your child imitate or copy your actions? (e.g., the adult claps hands and says "do this....." and the child copies and claps hands)

Yes No Sometimes
Can your child simple one step instructions? (e.g., "come here", "stand up", "wait", "stop"....etc)

Yes No Sometimes
Can your child match pictures/objects or colors?

Yes No Sometimes
Describe eating issues/concerns
Describe sleep issues/concerns

Toileting

Yes

Day

Night

Underwear

Diaper/Pull-up

Accidents

Wiping

Standing for boys

Describe toileting issue/concerns

Grooming/Hygiene

Independent

Needs Help

Full Assistance

Brushing Teeth

Washes Hands

Bath/Shower

Nose Blowing

Dressing

Independent

Needs Help

Full Assistance

Remove shoes & socks

Pulls up/down pants

Puts on & takes off shirt

Puts on shoes

Describe dressing & grooming/hygiene issues/concerns

Safety

Yes

Gets lost/wanders/leaves adult

Awareness around cars

Able to swim

Reduced attention to danger

Describe safety concerns/issues
Play Skills
Can your child engage in any of the following play skills? (click all that apply)

Sensory or repetitive play (pouring, sand, swinging...etc) Cause & effect toys (toddler toys) Shape sorters/simple puzzles...etc Pretend/imaginary play (dress-up, doll house, superhero ...etc) Build with blocks/legos/Lincoln logs..etc Play simple games (memory, candyland, tag, hide & seek..etc.) Color or draw independently as play
What does your child like to play with or do most of the time?
Learning Skills
Can your child complete age-appropriate puzzles?

Yes No Sometimes
Describe play issues/concerns
Challenging/Problem Behaviors
Does your child have any of the following problem or challenging behaviors?

Hyperactivity Impulsive Tantrums/Crying/Fits Low frustration tolerance Reduced attention span Does not learn from experience Destructive to property Sleep disturbances Frequent accidents (falls, trips...etc) Unusual fears Non-compliance Verbal protest Aggression towards others (hitting, kicking, scratching, pinching, biting...etc) Flops to the floor Running away/bolting Self-harm Headbanging Drooling Staring episode (spacing out) Poor memory Eating un-edibles Nightmares Repetitive Movements ("stimming") Sensory aversions ( doesn't like to touch, smells, loud sounds or covers ears) Obsessions or fixations Doesn't like change, inflexible or rigid
How well does your child accept being told "No" ?

Accepts being told "no" or pretty well no problem behaviors and easily redirected Makes a fuss or protests for a bit when told "no" but can be redirected Tantrums (crying, protesting, yelling, or screaming) when told "no" and takes a while to calm down. Hit or become aggressive when he is told "no" to something is taken away from him
How does your child respond when you have to take away something he/she wans a toy or preferred item away? ?

Does not have any problem behaviors and is easily redirected to something new He makes a fuss or protests for a bit but can be redirected He will tantrum (crying, protesting, yelling, or screaming) when something he wants is taken away and it takes a while to calm down. He will hit or become aggressive

How easy are transitions or change of activities for your child through out the day (e.g., going out to the car, leaving places, going to bed....etc)

	1	2	3	4	5

1 is Most difficult (tantrums/aggression), 5 is Easy - no problems

How easy is it for your child to be stopped or redirected when he is doing something he should not (e.g., running away in public, grabbing for things they shouldn't...etc)

	1	2	3	4	5

1 is Most difficult (behaviors), 5 is Easy - no problems

How well does your child respond to you teaching new skills or requiring more independence? (e.g, independent feeding, dressing, talking, asking for what they want without crying...etc)

	1	2	3	4	5

1 is Very resistant to being independent, 5 is Eager to learn and be independent

Describe behavior concerns/issues
Does your child approach and interact with most adults?
How well does your child socialize with other peers?

How interested are you in learning and trying new parenting strategies with your child?

	1	2	3	4	5

1 is Don't want to change my parenting at all, 5 is Eager to learn new strategies and tools to help my child

Please provide a copy of your child's prescription for ABA services or the physician's letter of medical necessity, if available *

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Please provide a copy of your child's Autism diagnosis report *

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Please provide a copy of your child's Individual Education Plan (IEP) if available

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Any other recent evaluations/reports if available

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My signature on this form acknowledges that I have received Child Enrichment Notice of Privacy Practices. I understand that this document explains the ways that Child Enrichment Center may use or disclose my child’s personal information and my child’s rights with respect to my child’s service information. *

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