StudentScholars: Intake Form

Child's First and Last Name

Child's Birthday

Year

Month

Day

Child's Gender

Any Medical Information/Conditions/Allergies We Should Know About? If 'Yes', Please Explain & Mention Any Immediate Medical Attention Required

Parent/Guardians First & Last Name

Parent/Guardian's Email

Primary Parent/Guardian's Phone

Secondary Parent/Guardian's Phone

Current Concerns: Primary Behaviour or Challenges of Concern

Behaviour Concerns: Challenging Behaviours & Triggers

Speech and Language Development: Are there any concerns about speech or language development?

Other (please specify)

Social and Communication Skills: Are there concerns with social interactions?

Other (please specify)

Motor Skills: Are there concerns with motor skill development?

No concerns

Difficulty with fine motor skills (e.g., grasping small objects, using utensils)

Difficulty with gross motor skills (e.g., running, jumping)

Poor coordination

Delayed walking or crawling

Other (please specify)

Cognitive and Learning Skills: Are there concerns with cognitive or learning abilities?

Other (please specify)

Sensory Sensitivities:

Are there any sensory sensitivities?

No sensitivities

Sensitivity to sounds (e.g., loud noises, background noise)

Sensitivity to textures (e.g., certain fabrics, food textures)

Sensitivity to lights or visual stimuli

Sensitivity to smells

Preference for certain sensory input (e.g., spinning, touching certain objects)

Other (please specify)

Is there anything you want to share with us?

Which programs are you interested in?

ABA Therapy - Help with behaviour

Speech/Phonics Language Program - Learn sounds, alphabet , sight words, and transition to the language program

Art Therapy - Helps with focus and behaviour

Music Therapy - Helps with focus and behaviour

Foundations in Math - Foundation skills in math