Intake Form

Child's First Name

Child's Last Name

Birth Date (ie: July 21, 2007)

Diagnosis Date (ie: July 10, 2010)

Family Member 1 (First and Last Name)

Family Member 2 (First and Last Name) - Parent or Sibling

Family Member 3 (First and Last Name) - Parent or Sibling

Family Member 4 (First and Last Name) - Parent or Sibling

Family Member 5 (First and Last Name) - Parent or Sibling

Family Member 6 (First and Last Name) - Parent or Sibling

Address (Including Postal Code)

Home Phone

Work Phone

Email Address

Describe the team currently working with your child (include name, title, contact info and how often your child sees each team member).

List and describe areas of concern

List and describe any communication issues or difficulties

List and describe any learning issues or considerations

Interests (hobbies, sports, preferred activities - vocational & recreational)

Recent significant events in your child's life

Getting Started: Which steps have been completed so far? Getting Started: Which steps have been completed so far? Contacted intake worker at Ministry for Children & Family Development (MCFD) Received 2 funding agreements from Autism Funding Unit in the mail Returned via mail 2 signed funding agreements to Autism Funding Unit

Other funding sources: Please describe

Best Days & Times for home therapy (click on a day to see times) Best Days & Times for home therapy (click on a day to see times) Monday Tuesday Wednesday Thursday Friday

Monday Availability Monday Availability 9 am 9:15 am 9:45 am 10:00 am 10:15 am 10:30 am 10:45 am 11:00 am 11:15 am 11:30 am 11:45 am 12:00 pm 12:15 pm 12:30 pm 12:45 pm 1:00 pm 1:15 pm 1:30 pm 1:45 pm 2:00 pm 2:15pm 2:30pm 2:45pm 3:00 pm 3:15 pm 3:30 pm 3:45 pm 4:00 pm 4:15 pm 4:30 pm 4:45 pm

Tuesday Availability Tuesday Availability 9 am 9:15 am 9:45 am 10:00 am 10:15 am 10:30 am 10:45 am 11:00 am 11:15 am 11:30 am 11:45 am 12:00 pm 12:15 pm 12:30 pm 12:45 pm 1:00 pm 1:15 pm 1:30 pm 1:45 pm 2:00 pm 2:15pm 2:30pm 2:45pm 3:00 pm 3:15 pm 3:30 pm 3:45 pm 4:00 pm 4:15 pm 4:30 pm 4:45 pm

Wednesday Availability Wednesday Availability 9 am 9:15 am 9:45 am 10:00 am 10:15 am 10:30 am 10:45 am 11:00 am 11:15 am 11:30 am 11:45 am 12:00 pm 12:15 pm 12:30 pm 12:45 pm 1:00 pm 1:15 pm 1:30 pm 1:45 pm 2:00 pm 2:15pm 2:30pm 2:45pm 3:00 pm 3:15 pm 3:30 pm 3:45 pm 4:00 pm 4:15 pm 4:30 pm 4:45 pm

Thursday Availability Thursday Availability 9 am 9:15 am 9:45 am 10:00 am 10:15 am 10:30 am 10:45 am 11:00 am 11:15 am 11:30 am 11:45 am 12:00 pm 12:15 pm 12:30 pm 12:45 pm 1:00 pm 1:15 pm 1:30 pm 1:45 pm 2:00 pm 2:15pm 2:30pm 2:45pm 3:00 pm 3:15 pm 3:30 pm 3:45 pm 4:00 pm 4:15 pm 4:30 pm 4:45 pm

Friday Availability Friday Availability 9 am 9:15 am 9:45 am 10:00 am 10:15 am 10:30 am 10:45 am 11:00 am 11:15 am 11:30 am 11:45 am 12:00 pm 12:15 pm 12:30 pm 12:45 pm 1:00 pm 1:15 pm 1:30 pm 1:45 pm 2:00 pm 2:15pm 2:30pm 2:45pm 3:00 pm 3:15 pm 3:30 pm 3:45 pm 4:00 pm 4:15 pm 4:30 pm 4:45 pm