Special Needs Intake Questionnaire
General Information
Child's Name
Date of Birth
Parent/Guardian Name
Phone Number
Email Address
Diagnosis & Medical Details
Diagnosis
Relevant Medical History
Current Medications
Known Allergies
Primary Physician
Development & Education
Current School/Program
Does the child have an IEP or 504 plan?
IEP
504
None
Received Services (e.g. OT, PT, Speech)
Daily Living & Behavior
Primary Communication Method
Mobility Needs
Behavioral Concerns
Interests and Strengths
Other Notes
Goals for Participation/Support
Additional Information