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Nurturing Families - Alta Vista Integrated Life Services
1950 Pottery Ave, Ste. 124
Port Orchard, WA 98366
Office: (360) 355-8969
Fax: (253) 857-5447
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Client/Student Name:
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Guardian Name:
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Client DOB:
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Address:
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Guardian Phone:
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Email Address
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Every client is required to bring a packed dinner for teen and adult programs. We do have a microwave and fridge available.
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Program of Interest:
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Social Groups/Therapy/Behavior Support
Respite
Early Childhood Education
Elementary Education support
Other:
Insurance & Policy # and/or Self-pay:
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DDA case manger name & contact (if applicable):
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Medical Diagnosis:
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Toileting assistance?
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Food Allergies:
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Medical Doctor & Contact:
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Medical Alert & Procedures:
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2 Emergency Contacts: (Name and Phone Number)
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Persons Authorized to Pick-Up:
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Sensory Issues:
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Communication Needs:
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Behavioral Challenges:
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Strengths:
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Favorite Foods:
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Favorite Characters:
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Favorite Music:
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Favorite toys/hobbies:
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Best methods to help calm:
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Goals:
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How many days If care would you like to participate in?
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1 day a week
2 days a week
3 days a week
4 days per week
Other:
What program will your child be attending.
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9am-12pm ( 3-6 yrs old )
12:30-4:00pm (7-12 yrs)
4:15pm-7:45pm (13-adult)
Any additional information:
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I understand I am liable for any co-pays required from my insurance, related to therapy services.
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