Child Intake Questionnaire





Child Information

*required
*required
*required
*required
*required
*required
*required
*required



School Information

*required
*required
*required
*required



Family Information

*required
*required
*required
*required
*required
*required
*ensure you enter a valid email address
*required
*required
*required
*required
*required
*required
*ensure you enter a valid email address
*required


Ensure you fill all required fields before you proceed






Development Information

Please indicate the age at which your child did the following:






Social Skills

Please indicate if your child is experiencing any of the following:






































































Self-care

How well does your child complete each of the following?
















Daily Routines

Describe your child's basic daily routine (include times to wake up, naps, bedtime, meals, school, etc)






List any serious operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child has had:



Allergies

Please select any of the following conditions that your child has had:






Medications

List any medications your child is currently taking or has taken for extended periods:









































Behaviors of Concern

















Please provide more details concerning challenging behaviors below.










Extra-Curricular Activities

Please indicate any extra-curricular activities, including sports, clubs, hobbies, lessons, etc:






Related Services





Consent

Inputing your name and date below indicates that you have read the information in this form and agree to be bound by its terms, and that you have received the HIPPA notice or have been offered a copy and declined. Consent by all parents/legal guardians (those with legal custody) is required.