The Whole Child Intake Form - Under 18 Programming
Thank you for your interest in The Whole Child Under 18 Programs - Use this form for:
Social Empowerment Groups, Art Experiences, Executive Functioning and Therapeutic Academic Coaching
Please answer the following questions to the best of your ability.  
These questions are designed to get to know your child and assist us in placement decisions.  
There are no "wrong" answers!
Our programs are designed to be flexible to address both your student's strengths and their challenges.

Please fill out a separate form for each student you wish for us to get to know. Thank you!
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Email *
Guardian's Name(s) *
Guardian's Relationship to Client
Any other Guardian's Email(s)
Guardian's Phone Number *
Student's Name (w/ Nickname, if any) *
Date of Birth *
MM
/
DD
/
YYYY
Current Grade (2021-2022 School Year) *
Current School District *
Which service(s) would you like to consider? *
Required
Does your student have an IEP or 504? *
If yes, please list goal areas.  You may also submit a copy of the current IEP at your intake appointment.
Does your student have a Behavior Support Plan? *
Has your student attended a Social Skills Group in the past? (at TWC or another provider)
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