Capable Companions Intake Form 2026-2027
As Salaamu Alaikum,
Thank you for your interest in Capable Companion's Weekend School Program on Saturdays. It is the very first program at ICLI which is inclusive of children with special needs in Nassau County.
Please fill out this form according to your child's most recent IEP.  

Things to Know:
- All information provided on this form will be kept strictly confidential.
- This intake form does not guarantee admission.
- Formal interviews will be conducted and an email will be sent to specify date and time of interview.
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Child's Full Name *
Child's Date of Birth *
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Child's Age *
Child's Grade *
Child's Address *
Mother's Full Name *
Mother's Phone Number *
Mother's Email *
Father's Full Name *
Father's Phone Number *
Father's Email *
Which parent is the primary contact? *
What is the best way to reach the primary contact? *
Does your child receive OPWDD services? If yes, please describe what services they receive. *
Please answer the following questions based on the child's most current IEP:
Child's diagnosis. Please check all that apply:
 *
Required
Services recommended for the child on their IEP *
Required
Recommended learning environment *
Does Child receive ABA Therapy *
Required
If 'yes', how many hours of ABA therapy a week? *
Does the child receive Paraprofessional services? *
Required
Are there any behavior modifications the child is currently working on? If yes, please explain. *
Is your child able to use the bathroom independently? (Please note we are not able to provide assistance in the bathroom.) *
Are there any specific accommodations your child may need? If yes, please explain. *
What are the things your child is interested in (ie, activities, toys, characters, tv shows)? *
What are some "motivators for your child? *
Describe your child's overall personality in a few sentences. *
What are some of your child's strengths? *
What are some of your child's challenges? *
Does your child have any allergies? If yes, please list allergies. *
Please list any medication(s) the child may be taking *
Parent / Guardian's Signature *
Date *
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