Section 1 of 1
Raise The Bar-n Intake Form
I am excited to get to know your family. Please answer the following questions to better help me understand your child and his/her needs. Thank you, Dr. Kerry Quinney
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we came there yesterday for a field trip and would love to get some information on my son volunteering.
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Natalie Cox
Natalie Cox
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702-321-5065
702-321-5065
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Nataliewebb25@gmail.com
Nataliewebb25@gmail.com
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Trenton Brown
Trenton Brown
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12
12
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sibling- Sister-Kylie age 13
sibling- Sister-Kylie age 13
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some of trenton's gavorite activities are video games,
some of trenton's gavorite activities are video games,
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Please
describe any aversions/triggers (things that may upset your child), such as too much noise, change to routine, etc.). If none, state "None":
Please
describe any aversions/triggers (things that may upset your child), such as too much noise, change to routine, etc.). If none, state "None":
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How
does your child adapt to new situations? How does he/she transition to new places or between activities?
How
does your child adapt to new situations? How does he/she transition to new places or between activities?
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What are your child’s strengths?:
What are your child’s strengths?:
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Describe
any allergies/pertinent medical conditions. State "None" if none:
Describe
any allergies/pertinent medical conditions. State "None" if none:
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Please
describe your child’s communication needs and how he/she communicates with you
at home (Speech, gestures, PECS, speech-generating device, etc.):
Please
describe your child’s communication needs and how he/she communicates with you
at home (Speech, gestures, PECS, speech-generating device, etc.):
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If your child uses an electronic speech-generating-device to communicate, please state which device or app (eg. iPad with ProloQuo2Go, TD Snap, Go Talk, etc):
If your child uses an electronic speech-generating-device to communicate, please state which device or app (eg. iPad with ProloQuo2Go, TD Snap, Go Talk, etc):
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Does your child attend school or is he/she homeschooled?
Does your child attend school or is he/she homeschooled?
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Attends CCSD
Attends Charter School
Homeschooled
Other:
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If your child attends school, please state name of school:
If your child attends school, please state name of school:
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Please check anything that applies to your child:
Please check anything that applies to your child:
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Individualized Education Program (IEP)
Behavior Intervention Plan (BIP)
504
None of the Above
Other:
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Does your child have an outside Diagnosis (from neurologist, pediatrician, etc.) and if so, please state disability (eg. autism level 2, intellectual disability, ADHD, etc). State "none" if not applicable:
Does your child have an outside Diagnosis (from neurologist, pediatrician, etc.) and if so, please state disability (eg. autism level 2, intellectual disability, ADHD, etc). State "none" if not applicable:
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Does your child receive any therapy outside of school?
Does your child receive any therapy outside of school?
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Applied Behavior Analysis (ABA)
Speech
Occupational Therapy
Physical Therapy
Other:
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Are
there any extenuating circumstances within your family that would help us to
understand your child better? (divorce/separation,
new family/recently remarried, foster situation, homelessness, death in family,
etc.)
Are
there any extenuating circumstances within your family that would help us to
understand your child better? (divorce/separation,
new family/recently remarried, foster situation, homelessness, death in family,
etc.)
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Other
important information you would like me to know:
Other
important information you would like me to know:
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