Client Intake Form

Date:*

Email:*

Parent/s or Guardian/s name:*

Home address street:*

City:*

State:*

Zip code:*

Primary Phone:*

Secondary Phone:

Are you in the military or a teacher? (Discounts or incentives):*

Childrens names and DOB:*

Pets? List names:*

Language/sign language:*

Mask required in the home?*

Yes

Not Required

Top 5 house rules:*

Screen time limitations:*

What time do your children go to sleep?:*

If my child has trouble falling asleep I usually:*

House phone policy (answer, let go to voicemail):*

Favorite things to do:*

Favorite food /snack:*

Least favorite food:*

Fun fact about your family:*

Needs such as light cleaning, cooking, shopping or driving family car:*

Emergency contact 1 (name and phone):*

Emergency contact 2 (name and phone):*

Emergency contact 3 (name and phone):*

Emergency contact 4 (name and phone):*

List of Allergies:*

Preferred Urgent care:*

Preferred Hospital:*

My child is afraid of:*

People involved with my child’s care 1.Name / Relationship:

2.Name / Relationship:

3.Name / Relationship:

4.Name / Relationship:

Anything else you would like to share about your child?: