Parent Intake Form

Thank you for taking the time to complete this intake form. The information you provide here will help Achieve complete a through evaluation of your child. Please complete all items if possible. If you have any questions, please contact us.

APPLICANT INFORMATION

* Indicates required field

Student Name *

First

Last

Student Middle Name *

Preferred Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date Of Birth *

Current Age *

Social security *

Choose Any *

Male Female

REFERRAL SOURCE

How did you hear about us? *

First Name *

Last Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

RELATIONSHIP TO APPLICANT *

May I have your permission to thank this person for referral? *

Yes No

How did this person explain how I might be of help to you? *

BIRTH HISTORY

1. Is your child adopted? *

Yes No

Dose s/he know? *

Yes No

If yes what age? *

2. Where was your child born *

3. Was your child born: *

Full-term Overdue Premature

If premature how many weeks? *

4. Was the pregnancy planned? *

Yes No

5. Did the child's mother or baby have any problems during pregnancy or delivery *

Yes No

If yes please describe them: *

7. Did your child's mother smoke tobacco or use any alcohol, drugs or medications during the pregnancy: *

Yes No

If yes which ones: *

8. Did the mother feel depressed after the baby's birth? *

Yes No

9. Please list an\y health issues for baby's first two years *

10. Developmental milestones: Please rate your child on each of the following.

Smiled *

Fed self *

Toilet Trained *

Sat up without support *

Said 1st word *

Dressed self *

Stood *

Said phrases *

Crawling *

Walked *

Read *

Tied shoes *

11. Please explain any milestones rated other than A (average): *

12. During the Child's first year if life, was anything present in the life of the mother or father Which caused unhappiness or anxiety or which placed either parent under special strain (even if the event had nothing to do with the baby)? If yes, please explain: *

Yes No

If yes, please explain *

APPLICANT'S FAMILY HISTORY

1. The name of the child's biological parents:

Mother: *

Father: *

2. Martial status of biological parents: *

3. Who has legal guardianship of your child? *

4. Primary language(s) spoken in child's home: *

5. Child's ethnicity and cultural background:: *

6. Please describe any past counseling that either your child or family have had: *

7. In your family, including yourself, was there:

9. Whom can you depend on when you need help? (Please include any church or community programs.) *

10. What stresses dose your family struggle with? *

11. How often dose your family have dinner together? *

12. What percentage of holidays dose your family spend together? *

13. How often, and what activities do you do together as a family (church, sports, etc.)? *

Applicant's Education

1. What school dose your child currently attend? *

2. current grade: *

has your child ever skipped or repeated a grade? *

Yes No

If yes, were they skipped or repeated? *

Skipped Repeated

If yes, which grade(s) *

3. Child's Favorite Class(es)/ Subject(s) *

Least Favorite Class(es)/ Subject(s) *

4. Has your child ever received special education services? *

Yes No

5. has your child received any academic or psychological testing done at school or elsewhere? *

Yes No

If yes, when and where? *

6. what do school teachers/ personnel tell you about your child? *

Applicant's Routine

1. What kind of physical exercise dose your child get? *

2. How much coffee, cola, tea, or other caffeine dose your child consume each day? *

3. is your child's eating restricted in any way? How? Why? *

4. Bedtime: *

Wake-up time: *

Avg. hours of sleep/night: *

5. Dose your child have any problems getting sleep? *

Yes No

Please describe fully: *

6. Curfew: A) school nights *

B) weekend/ holiday nights: *

7. List assigned chores and how well s/he dose them: *

8. Describe the discipline program you use at home: *