All Access Intake Form

Your name *

Email address *

Parent/Household Information

Address

Phone number

Child's First Name *

Child's Last Name *

Child's date of birth *

Gender: *

Diagnosis/Special Needs: *

Preferences: *

Dislikes: *

Things that sooth/calm: *

Things that agitate or over stimulate: *

Ways positive behavior/communication is reinforced: *

Allergies, dietary restrictions, or physical assistance we should be aware of: *

If nonverbal, how does he/she communicate best? Sign language, general gestures, behavior?

Bathroom procedure: *

Does the child put things into their mouth where we should be aware of any choking risks?

Run risk: *

Things you want us to know: *

Please list any questions you have: