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Testimonials
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Client Intake Questionnaire
Thank you for completing our client intake form. Please provide as much information as possible. if you have any questions, please let us know.
Name for Parent/Guardian #1
*
First Name
Last Name
Email Address for Parent/Guardian #1
Name for Parent/Guardian #2
First Name
Last Name
Email Address for Parent/Guardian #2
Child's Full Name (including middle name)
*
Child's Date of Birth
*
MM
DD
YYYY
Child's Gender
Male
Female
Child's Handedness
Left Handed
Right Handed
Shows no preference
Child's Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's Race/Ethnicity
African American
Asian
Hispanic
Caucasian
Bi-Racial
Other (please fill in below)
What is the primary language spoken in your home?
Do you or your child speak additional languages?
Is your child currently living with both parents?
Yes
No
If not, please describe the legal custody arrangement.
Is your child adopted?
Yes
No
Has your child ever been in foster care?
Yes
No
Please list the names of any other children or family members living in the household.
Name (Additional Child 1)
First Name
Last Name
Relationship to the Child
Age
Gender
Male
Female
Name (Additional Child 2)
First Name
Last Name
Relationship to the Child
Age
Gender
Male
Female
Name (Additional Child 3)
First Name
Last Name
Relationship to the Child
Age
Gender
Male
Female
Child's Grade in School
Name of Child's School
Child's School's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please provide the names and titles of any other relevant school team members:
(i.e. Speech and Language therapist, Occupational Therapist, etc.)
Would you like to provide Kid’s First Collaborative with consent to communicate with your child’s school team on your behalf?
Yes
No
What do you see as your child’s strengths?
What do you see as your child’s areas of need?
Did you have concerns about your child’s early development? If so, when did you first become concerned about your child’s development? Please explain.
Does your child have any behavioral or social emotional problems at home or at school? If so, please explain.
Does your child have any learning problems at home or at school? If so, please explain.
Do you have any concerns about your child’s sensory needs? If so, please explain.
Do you have any concerns about your child’s health? If so, please explain.
Does your child have any medical or psychiatric diagnoses? If so, please explain. Please include any medications that your child is currently taking.
Has your child ever been hospitalized? If so, please include the approximate dates and reasons for hospitalizations.
Has your child ever been evaluated by a neurologist, neuropsychologist, or developmental pediatrician? If so, what were the reasons for this evaluation? What were the results? Please include any diagnoses and attach any evaluation reports.
Has your child ever experienced any trauma (i.e. life threatening illness, loss of loved one, parent/caretaker with life threatening illness, emotional, physical, or sexual abuse of any kind?) If so, please explain.
Does your child currently have an Individualized Education Plan?
Yes
No
If so, when was your child’s IEP initially developed?
Does your child currently have a Section 504 plan?
Yes
No
If so, when was your child’s 504 plan initially developed?
Please indicate whether your child receives any of the following therapies at school.
Speech and Language Therapy
Occupational Therapy
Physical Therapy
Vision Therapy
Hearing Itinerant Services
Nursing
Other (please explain below)
Please indicate whether your child receives any of the following therapies at home or in a clinic/private practice setting:
Speech and Language Therapy
Occupational Therapy
Physical Therapy
Vision Therapy
Hearing Itinerant Services
Nursing
Other (please explain below)
Is your child currently participating in interventions for reading at home or at school? If so, please describe.
Is your child currently participating in interventions for math at home or at school? If so, please describe.
Is your child currently participating in interventions to support executive functioning skills?
Please describe your relationship with members of your child’s school team.
(i.e. teachers, therapy providers, administrators)
Do you feel meaningfully included in educational decision regarding your child at school? Please explain.
How would you like Kid First Collaborative to help you and/or your child? What would you like to be different as a result of your work with Kids First Collaborative?
Thank you!
Your questionnaire has been received. If we have any questions, we will be in touch.
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