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:*
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?: