Intake Assessment Form

Participant Full Name *

First

Last

Gender *

Date Of Birth *

Age *

Race

Social Security *

Medicaid # *

Father’s Name:

First

Last

Father's Phone Number

Mother’s Name:

First

Last

Mother's Phone Number

Referral Information

Date of Referral *

Referral Type *

Referral Source Name *

First

Last

Mother’s Contact Information

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Cell Phone

Home Phone

Office Phone

Father’s Contact Information

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Cell Phone

Home Phone

Office Phone

Emergency Contact Information (Besides Parents)

Full Name *

First

Last

Relationship *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Cell Phone

Home Phone

Office Phone

School Contact Information

Name Of School *

School Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number *

Fax Number

Contact Person (Name) *

First

Last

Service Coordinator Information

Full Name *

First

Last

Country *

Phone Number *

Describe some things about your child

What are their strengths?

Make a list

What do they need help with (weakness)?

Make a list

Any new skills they’d like to learn?

Make a list

What are their hobbies?

Make a list

Favorite food/snacks are:

Make a list

For Feeding:

Needs help with feeding
Can feed myself independently

What makes them mad?

Make a list

What behaviors do they engage in?

Make a list

How do you manage the behaviors?

Make a list

For Communication:

Verbal
Non-verbal
Sign language
Use PECs
Others

For Toileting:

Fully toilet Trained
Not yet toilet trained
I am trained but require supervision

For good performance & behavior, I like to be rewarded with:

Make a list

My disabilities/diagnosis include:

Make a list

Allergies:

Please list Food Allergies, Seasonal Allergies and any other allergies if any.

Unusual health problems

Please list if any

Any medications?

If Yes, please list all medications, administration times & dosages below

The house rules we should know about:

Please list if any

My Service Needs

I'd like Oaks Dynamics to provide the following services:

IISS
Therapeutic Services(
Respite
Family Training (FT)

Please indicate days, start and stop time when service will be required:

E.g: IISS on Mondays, Tuesdays and Thursdays. TI on Wednesdays and Fridays...

Anticipated Start Date

End Date (For Non-Waiver)

I'd Need Transportation Services:

To School in the morning
From School to TI center
From TI center to Home
To Community
Others

Other Comments:

During Transportation

I do NOT need supervision
I need a harness
I need supervision
Others

Other Comments

I'd prefer to be cared for by a:

Male
Female

I currently have a preferred caregiver

If Yes, Please Provide Name & Phone No. below.

My TI Services Requirements

In A Group Setting:

I can transition easily
I may be shy
I have no problems integrating in a group
I may exhibit certain behaviors such as:

I may exhibit certain behaviors such as:

Please list if any

My TI Services will be Provided Mainly at:

Oaks Dynamics TI Center
Community
Both TI Center & Community

I'd be Dropped Off at Oaks Dynamics TI by:

School Bus
Oaks Dynamics Van
TI Technician
IISS Technician
Parent/Family Member

I'd be Picked Up from Oaks Dynamics TI by:

School Bus
Oaks Dynamics Van
TI Technician
IISS Technician
Parent/Family Member

Summary of Daily Activities

Below is a Summary of My Daily Activities:

Please make a list of your daily activity you think we should know about.

Captcha *

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