Intake Form

Name

First Name

Last Name

Date of Birth

YYYY

Age

Parent 1 Name (if under 19)

First Name

Last Name

Parent 1 Phone

(###)

###

####

Parent 1 Email

Parent 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 2 Name

First Name

Last Name

Parent 2 Phone

(###)

###

####

Parent 2 Email

Parent 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Siblings names and ages

School

Grade

Diagnosis

Please list any or all diagnoses that your child has, if applicable.

IEP

Does your child have an IEP, please attach a copy if possible.

SLP/OT/Physio

Please list specialists your child sees regularly.

Personal Info

If we were to observe your child at school during class, what would they look like?

If we were to observe your child at school during lunch or recess, what would they look like?

If we were to observe your child at home during unstructured time, what would they typically be doing?

Do you have any behavioral challenges at home?

Does your child have any behavioral challenge at school?

Does your child have an EA at school?

Brief Letter to Us

Please write a brief letter describing your child.

Please write a brief letter describing your child. We know your child is unique and we’re excited to learn about them. Before we do, any info you can give us is very helpful!! Please provide us with a letter outlining your child’s strengths, difficulties, interests, etc. For example, you could include info about some or all of the following skills: - Typical interactions with peers look like… - Friendships - Self-confidence - Language capabilities - Motivation to please others - Awareness of their difficulties - Organizational skills - Being part of large or small groups - Problem solving - Manipulation (by them, or by others) - Etc.

So Social #110- 585 16th Street West Vancouver, BC (ABLE Clinic)

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