New Student Intake Form
Please answer the following questions so we can determine the best way to meet your child's needs.
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Email *
Student Name *
Your Name *
Primary Phone Number *
Is this a Cell Phone? *
Required
Secondary Phone Number
Is this a Cell Phone?
Address *
Student's Date of Birth *
MM
/
DD
/
YYYY
Child's diagnosis/Issues? *
Student's Weight (Estimate is fine) *
Student's Height *
Please give us some information about your child *
Yes
No
Can they walk?
Do they talk?
Can they sit up alone?
Can they hold their head up?
Are they blind/sight impaired?
Are they deaf/hearing impaired?
Currently all students who are not vaccinated must wear a mask *
Yes
No
Can they wear a mask?
Are they vaccinated?
Please tell us about any assisted devices your child uses (wheelchair, walker, hearing aids, etc.)
Please tell us about any behavioral issues your child has and successful management strategies you use
Which location are you interested in? *
Required
What days are you available? *
Required
What is the earliest time of day you are available? (Currently lessons are in the afternoon on weekdays and 9-2 on Saturdays.) *
Time
:
Do you plan to use Regional Center Funding? *
Which Regional Center services your child?
Clear selection
Is there any other information you would like to share?
May we add you to our email list while you wait for an opening? *
Thank you for completing the intake form; we will contact you as soon as we have an appropriate opening
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