Client Intake Form

Please enter all required fields to submit.

Services can be provided in the following settings:

Home
School
Daycare/Nursery
The community

Children may be referred by a physician. Alternatively, families can also access our services by self-referral.

"*" indicates required fields

Child's Information:

Child's Full Name*

First Last

Date of Birth*

Gender

Current Age*

Age at Diagnosis

If Applicable

Parent/Guardian Name(s)*

First Last

Parent/Guardian Name(s)

First Last

Address

Street Address Address Line 2 City ZIP Code

Phone

Primary Concerns and Goals:

What are your primary concerns regarding your child's development, behaviour, or emotional well-being?*

Please describe any specific goals you would like to achieve through therapy*

What therapy are you interested in?*

Do you have OAP funding?*

Communication Abilities and Challenges:*

Interests and hobbies:*

Preferred activities:*

Any additional concerns:

Medical Information:

Name of Paediatrician/Physician:*

First Last

Address*

Street Address Address Line 2 City Postal Code Country

Phone*

Email*

Has your child undergone any medical evaluations related to ASD or any other conditions? If yes, please provide details:*

Educational Information:

Name of School/Preschool/Daycare:

Grade/Class:

Special Education or Additional Services Received (if applicable):

Is your child currently receiving any therapy or intervention services?

If yes, please provide details:

Previous Therapies/Interventions:

Has your child received any previous therapy or interventions for ASD or related concerns? If yes, please provide details (e.g., type of therapy, duration, outcomes):

Behavioural Challenges:

Please describe any challenging behaviours exhibited by your child

(e.g., difficulties with communication, social interaction, sensory sensitivities, repetitive behaviours):

List any triggers or factors that may be influencing challenging behaviours:

List coping strategies in place (if any):

Please provide any additional information you believe is relevant to your child's therapy needs:

Client Intake Form

Child's Information:

Primary Concerns and Goals:

Medical Information:

Educational Information:

Previous Therapies/Interventions:

Behavioural Challenges:

on the autism spectrum