Initial Client Information Form
Client Name (First, Middle Initial, Last)
Individuals who have obtained an appointment for an initial consultation may submit their client information in advance of their appointment, by filling out and submitting the following information.  This form is specifically designed for individuals, who are seeking assistance for children with disabilities in public school.  Individuals seeking different services may disregard irrelevant questions.
Client Mailing Address
Street & Apt #
City,                                         State,    Zip Code
                         Partner/Spouse's Name
Information on Child requiring services
Telephone, Fax & Email Information
Telephone #                    Cell Phone #
Fax #Email Address
Child's Name
Date of Birth            Age        Grade
Child's Disability:  This portion of the form is intended to provide the maximum amount of information possible on your child and his/her disability.  We are sensitive to the fact that your child is a unique individual and our purpose is not to categorize or label your child.  In your initial consultation, we will ask many more questions, in order to have a full understanding of your child.
School District (County)
School Name
District Contact Person:  
Highest ranked Individual you have spoke with about your issues
NameTelephone #
Primary Disability 
Secondary Disability
Other
Other
Additional Description of the Child's Disability
Educational Documentation and Evaluations
Date of most recent IEP
Date scheduled for next IEP
Evaluations:  Please check which of the following evaluations have been done on your child and indicate in the box next to the checked evaluation was done.
Other Evaluation
Intellectual Level (I.Q.)
Services presently being provided:  Please check which of the following services are presently being provided to your child by the school district.  Next to the service indicate the amount of time per week your child is receiving each service.
Time/minutes per week
Areas of Concern and Issue with School:  Please check which of the following areas are concerns or issues, which you would like to see addressed.
Statement of Issues:  Please provide a statement of the principle issues that you wish addressed.

If for some reason you experience difficulty with the on-line form, please download the pdf file and submit by email or fax.  We have had some compatability difficulties with ipads and tablets.

Client_Intake_Form.pdf
Client_Intake_Form.pdf
How did you hear about us?
Psychological/educational
Physical Therapy
Occupational Therapy
Special ESE Class (full day)
Special ESE Class (parttime)
Speech/Language
Physical Therapy
Occupational Therapy
Paraprofessional Assistance
Inclusion or educational mainstreaming
Behavior Issues
Paraprofessional Assistance
Speech/Language
Assistive Technology
Occupational Therapy
Physical Therapy
Functional Behavior Assessment
Speech/Language
RtI Process