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 Date Picker Icon
Current Age
Gender

Address

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

Email *
example@example.com
Preferred Phone/Mobile Number

Area Code Phone Number
Diagnosis
Secondary Diagnosis
Date of Diagnosis

Month Day Year
Date Date Picker Icon
Diagnosed by
PARENT/GUARDIAN AND FAMILY INFORMATION
Mother's Name

First Name Last Name

Mother's Address

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

Mobile Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Occupation
Father's Name

First Name Last Name

Father's Address (if different)

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

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)
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)
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'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
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	No	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	No	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	No
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
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
Describe behavior concerns/issues
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 Individual Education Plan (IEP) if available

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Any other recent evaluations/reports if available

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

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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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