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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
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Indicates required field
Student Name
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First
Last
Student Middle Name
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Preferred Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Date Of Birth
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Current Age
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Social security
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Choose Any
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Male
Female
REFERRAL SOURCE
How did you hear about us?
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First Name
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Last Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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RELATIONSHIP TO APPLICANT
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May I have your permission to thank this person for referral?
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Yes
No
How did this person explain how I might be of help to you?
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BIRTH HISTORY
1. Is your child adopted?
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Yes
No
Dose s/he know?
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Yes
No
If yes what age?
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2. Where was your child born
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3. Was your child born:
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Full-term
Overdue
Premature
If premature how many weeks?
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4. Was the pregnancy planned?
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Yes
No
5. Did the child's mother or baby have any problems during pregnancy or delivery
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Yes
No
If yes please describe them:
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6. Please check any of the following which occurred during pregnancy:
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Prenatal Care
Nervous/Worried
Over/Underweight
Vomiting/Nausea
Good Nutrition
Chronic Disease
Unusual Stresses
Narcotics/Alcohol Intake
Accident
Measles
Flu/High Fevers
Headaches
Toxemia
Infections
Medication Intake
7. Did your child's mother smoke tobacco or use any alcohol, drugs or medications during the pregnancy:
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Yes
No
If yes which ones:
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8. Did the mother feel depressed after the baby's birth?
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Yes
No
9. Please list an\y health issues for baby's first two years
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10. Developmental milestones: Please rate your child on each of the following.
Smiled
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Average
Slower than average
Faster than average
Unknown
Fed self
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Average
Slower the average
Faster than average
Unknown
Toilet Trained
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Average
Slower than average
Faster than average
Unknown
Sat up without support
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Average
slower the average
Faster than average
Unknown
Said 1st word
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Average
Slower than average
Faster than average
Unknown
Dressed self
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Average
Slower than average
Faster than average
Unknown
Stood
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Average
Slower than average
Faster than average
Unknown
Said phrases
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Average
Slower than average
Faster than average
Unknown
Crawling
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Average
slower than average
Faster than average
Unknown
Walked
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Average
Slower than average
Faster than average
Unknown
Read
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Average
Slower than average
Faster than average
Unkown
Tied shoes
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Average
Slower than average
Faster than average
Unknown
11. Please explain any milestones rated other than A (average):
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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:
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Yes
No
If yes, please explain
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APPLICANT'S FAMILY HISTORY
1. The name of the child's biological parents:
Mother:
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Father:
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2. Martial status of biological parents:
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3. Who has legal guardianship of your child?
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4. Primary language(s) spoken in child's home:
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5. Child's ethnicity and cultural background::
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6. Please describe any past counseling that either your child or family have had:
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7. In your family, including yourself, was there:
A. Alcoholism?
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Yes
No
Who?
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Father
Mother
Siblings
Self
How long?
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Current Status:
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c. Mental Illness
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Yes
No
Who?
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Father
Mother
Sibling
Self
How long?
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Current Status:
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8. List major changes, including marriages, divorces, moves, deaths, etc., which have occurred in your family in the past 5 years. (If there are other events that happened earlier that still affect the family, please add those.)
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B. Substance Abuse?
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Yes
No
Who?
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Father
Mother
Siblings
Self
How long?
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Current Status:
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d. Serious illness
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Yes
No
Who?
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Father
Mother
Siblings
Self
How long?
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Current status:
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9. Whom can you depend on when you need help? (Please include any church or community programs.)
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10. What stresses dose your family struggle with?
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11. How often dose your family have dinner together?
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12. What percentage of holidays dose your family spend together?
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13. How often, and what activities do you do together as a family (church, sports, etc.)?
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Applicant's Education
1. What school dose your child currently attend?
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2. current grade:
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has your child ever skipped or repeated a grade?
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Yes
No
If yes, were they skipped or repeated?
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Skipped
Repeated
If yes, which grade(s)
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3. Child's Favorite Class(es)/ Subject(s)
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Least Favorite Class(es)/ Subject(s)
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4. Has your child ever received special education services?
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Yes
No
5. has your child received any academic or psychological testing done at school or elsewhere?
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Yes
No
If yes, when and where?
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6. what do school teachers/ personnel tell you about your child?
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7. Has your child experienced any of the following problems at school? (Check all that apply)
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Fighting
Suspension
Frustration
Lack of friends
Learning disabilities
Incomplete homework
Drugs/ Alcohol
Frequent absences
Behavior issues
Detention
Poor grades
Emotional issues
Applicant's Routine
1. What kind of physical exercise dose your child get?
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2. How much coffee, cola, tea, or other caffeine dose your child consume each day?
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3. is your child's eating restricted in any way? How? Why?
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4. Bedtime:
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Wake-up time:
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Avg. hours of sleep/night:
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5. Dose your child have any problems getting sleep?
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Yes
No
Please describe fully:
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6. Curfew: A) school nights
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B) weekend/ holiday nights:
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7. List assigned chores and how well s/he dose them:
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8. Describe the discipline program you use at home:
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Submit
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Home School
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About
Contact
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Employment