Client Intake Questionnaire


 
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Client forms and documents for ADVOCACY, CONSULTING, AND PSYCHODIAGNOSTIC ASSESSMENTS
 

Thank you for completing our client intake form. Please provide as much information as possible. if you have any questions, please let us know.

 
Kids First Collaborative client intake form
 
Name for Parent/Guardian #1 *
Name for Parent/Guardian #1
Name for Parent/Guardian #2
Name for Parent/Guardian #2
Child's Date of Birth *
Child's Date of Birth
Child's Gender
Child's Handedness
Child's Home Address
Child's Home Address
Child's Race/Ethnicity
Is your child currently living with both parents?
Is your child adopted?
Has your child ever been in foster care?
Please list the names of any other children or family members living in the household.
Name (Additional Child 1)
Name (Additional Child 1)
Gender
Name (Additional Child 2)
Name (Additional Child 2)
Gender
Name (Additional Child 3)
Name (Additional Child 3)
Gender
Child's School's Address
Child's School's Address
(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?
Does your child currently have an Individualized Education Plan?
Does your child currently have a Section 504 plan?
Please indicate whether your child receives any of the following therapies at school.
Please indicate whether your child receives any of the following therapies at home or in a clinic/private practice setting:
(i.e. teachers, therapy providers, administrators)