Client Registration Form

Client Intake Form

We greatly appreciate your time in completing this intake packet!

Step 1 of 5

Person(s) providing information*
Relationship to Client*
Client Information
Client’s Name*
First Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County
If you reside in Northeast Ohio, please specify the county in which you live.
Gender*
Age*
Birth Date*
MM slash DD slash YYYY
Race
Language(s)
School
Grade

Mother Information
Mother's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
E-mail Address
Occupation*
Work Phone
Race
Birth Date*
MM slash DD slash YYYY
Language(s)
Can you be contacted at work for non-emergency?*
Father Information
Father's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
E-mail Address
Occupation*
Work Phone
Race
Birth Date
MM slash DD slash YYYY
Language(s)
Can you be contacted at work for non-emergency?*
Other Family Member Information
Other Family Member's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Occupation
Work Phone
Race
Birth Date
MM slash DD slash YYYY
Language(s)
Can they be contacted at work for non-emergency?

Family Information
All persons living in household now
Please specify Name, Age, Gender, and Relationship to child.
Primary Payment Method*
Other Services
If your child is currently receiving other services, please complete.
Type of Service
Name of Agency
Contact Person
Email
Phone Number
Notice
I give permission to contact the above-mentioned contact persons to aid in coordinating services for my child.
- Yes
- No

Developmental History
Were there any problems during pregnancy? (bleeding, high blood pressure, etc.)
Were there any problems during delivery? (length of labor, Caesarean, lack of oxygen, etc.)
Birth Weight
Select if your child completed any of the following developmental milestones significantly late.
Select if you noted any special problems in these areas, during your child’s early years.
Is your child toilet trained?*
Indicate how your child completes the following
Independently (I), Little assistance (L), Much assistance (M), or Not at all (N).
Eat with spoon*
Eat with fork*
Use a knife*
Use scissors*
Use a crayon/pencil/marker*
Isolate pointer finger to press buttons*
Open flip lid*
Open twist cap*
Manage hot food/liquid safely*
Recognize basic safety signs*
Medical History
Describe child's diagnosis or indicate if an assessment for diagnosis is needed.*
Year of Diagnosis
Child’s General Physician’s Name*
Specialty Physician’s Name & Title
Specialty Physician’s Name & Title
Does your child have dietary restrictions?*
- No
- Yes
What foods/liquids?
Any environmental allergies?*
Does your child have any physical/health limitations?*
Has your child been hospitalized for any reason since birth?*
- No
- Yes
For what? When?
Please list ALL medications your child is presently taking
Please list Start Date, Drug Name, Reason, and Prescribing Physician.
Please list medications your child has taken in the past, but is no longer taking, other than for normal childhood illnesses
Please list Why Discontinued, Drug Name, Why Taken, and Date Last Taken.

Educational Information
Does your child attend school currently?*
- No
- Yes
Name of School
City
Number of days attend per week
Hours attend per day
Any problems at school?
If yes, please describe
Family Concerns
What is your primary goal for your child?*
What two things do you think your child needs to change to be more successful in school, the community, or at home?*
Cultural Information
What particular group or culture does your family identify with?
What specific religious or spiritual beliefs or traditions are important to your family?
Stressors
If applicable, explain any past or current stressful events in his/her life:
Changes in Living situation (moved, divorced, separation, etc.)
Death of a significant person
Other
Other Information
Please explain any further information that would be helpful in serving your child and your family better.
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Client Intake Form

Step 1 of 5

Client Information

Mother Information

Father Information

Other Family Member Information

Family Information

Other Services

Developmental History

Indicate how your child completes the following

Medical History

Educational Information

Family Concerns

Cultural Information

Stressors

Other Information