Child Intake Form for Prospective Families
If you would like more information about Respite Care and the services that we provide, please submit the following form. Our Child Care Manager will follow up with you shortly after receipt to discuss scheduling a facility tour or intake consultation to see if we are a good fit for you and your child. We look forward to hearing from you!
Today's Date
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Parent Name *
Your answer
Phone Number *
Your answer
Does your family live in Larimer County? *
Does your family receive services from Foothills Gateway? *
What is your child's name? *
Your answer
What is your child's age? *
Your answer
What is your child's diagnosis?
Your answer
Does your child have any health care needs?
Your answer
Child's School (if applicable)
Your answer
Does your child have an IEP or IFSP?
Your answer
How did you hear about Respite Care?
Your answer
Submit
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