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Intake Form
FAQ
About Us
Bio
Who We Help
Services
Our Therapists
What We Offer
Workshops
FSCD
Contact Us
Booking
Intake Form
FAQ
Therapy for children with special needs
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Intake Form
To access our services funded by FSCD, please fill out this intake form.
Childs Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Gender
Parent / Guardian
First Name
Last Name
Parent / Guardian
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone Number
Work Phone Number
Cellphone Number
Email Address
Family Members - Siblings
Name / Age
Name / Age
Name / Age
Name / Age
Other Caregivers in the home
Name
Name
Name
Name
Spoken language(s) in home
Marital Status of Parent
Married
Separated
Divorced
Other
If child has two home will therapy be taking place in both homes?
Yes
No
School Information
School Name
Teacher's Name (if applicable)
Grade
Does your child see a therapist at school? (OT, SLP, etc)
What is your availability for therapy visits?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
FSCD (Family Supports for Children with Disabilities)
Do you have an approved contract for Specialized Services with FSCD?
Yes
No
What is the name of your caseworker?
Diagnosis
Has your child been diagnosed with (Please check all that apply)
ASD
ADHD
Anxiety Disorder or Mood Disorder
Autism Spectrum Disorder
Cognitive Delay
Down Syndrome
Dyslexia
Genetic Disorder
Learning Disabilities
Sensory Processing Disorder or Sensory Integration Dysfunction
Other
Has your child had any previous testing and/or treatments? (e.g., SLP, OT, Psychology, Audiologist, Glenrose, other). Please forward any relevant reports along with intake form.
Medications
List any medications your child is currently taking:
Other relevant medical history:
What are your child’s strengths and areas of interest?
What are your main priorities and goals for therapy?
Any additional information you would like to include:
How did you hear about Growing Changes?
Thank you! We will reach out to you as soon as possible.
Specialized Services Intake Form
