Child Intake Form

Dream Pathways Foundation

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Child Intake Form

* Indicates required field

Parent's Name *

First

Last

Email *

Child's Name *

Child's Age *

Child's Ethnicity *

Select Grade Level *

Preschool Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade

Child's School *

What is the reason for the referral? *

Has your child been evaluated before? *

What are the presenting problems? *

When did the problems begin? *

Where do they occur? *

Does anything relieve or reduce the reported problems or symptoms? *

Please list all of your child's prescription medications *

Have there been any significant events or stressors in the child's home or family? Please describe. *

How do you think your child's problems affect their daily performance at school? at home? in other settings? *

When was your child's most recent medical exam? *

Please list all medical conditions if applicable *

How would you describe your child's overall health? *

Does your child have visual or hearing difficulties? *

Describe your family composition. Who lives in the household? *

What is the family's ethnic and cultural background? *

Please indicate family's income status *

under $10,000 $10,000-$35,000 $35,000-$50,000 $50,000-$75,000 $75,000-$100,000 $100,000+

My child has problems with... (check all that apply) *

staying on task completing tasks following directions controlling anger mood swings motivation learning keeping friends making friends respect for authority aggression towards others verbal expression getting dressed in the morning falling asleep at night staying asleep morning routine

How does the family handle the child's problems? *

How does your child spend their free time? *

What responsibilties/chores does your child have at home? *

What are your child's strengths? *

What type of interventions, including services would you like to receive for your child? *

Submit

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