StudentScholars:

Special Education Intake Form

Section 1: Student Information. Child's First and Last Name

Child's Birthday

Year

Month

Day

Child's Age

Child's Gender

Home: City and Postal Code

Section 2: Medical & Diagnosis Information Has your child ever been diagnosed?

If Yes, please specify

Other (please describe):

Who provided the diagnosis? (e.g. Pediatrician, Psychologist)

Date of Diagnosis (if applicable):

Does your child take any medication?

Yes

No

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

Section 3: Parent/Guardians First & Last Name

Parent/Guardian's Email

Primary Parent/Guardian's Phone

Secondary Parent's First & Last Name

Secondary Parent/Guardian's Phone

Section 4: Communication • Primary Language Spoken at Home

How does your child communicate?

Verbal (speaks in full sentences)

Limited verbal (single words, short phrases)

Non-verbal

Uses Augmentative Communication (e.g., PECS, device)

Uses gestures/sign language

Comments

Section 5: Learning & Development • Can your child follow multi-step instructions?

Yes

Sometimes

No

Can your child work independently for 5–10 minutes?

Yes

Sometimes

No

What areas does your child excel in or enjoy?

Other:

Section 6: Behaviour & Social Skills • How does your child interact with other children?

Plays cooperatively

Parallel play

Prefers to play alone

Needs support with social interaction

Does your child exhibit any of the following behaviors regularly?

If yes, please explain triggers and calming strategies: Sensory Sensitivities (check all that apply):

Describe any known triggers or supports used:

Section 7: Support Needs & Independence. Toileting:

Fully independent

Needs reminders

Needs full support

Feeding:

Fully independent

Needs assistance

Special diet

Explain special diet

Dressing (zippers, shoes, etc.):

Independent

Needs help

What supports does your child currently need in a classroom?

Other explain:

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)

Section 8: Parent Insights What goals do you have for your child at StudentScholars?

What strategies have worked well for your child at home or in therapy?

Parent Acknowledgment: Please read the information below carefully. By checking each box, you confirm that you understand and acknowledge the details of our Special Education services and policies. Understanding Developmental Differences. I understand

I understand that every child develops at their own pace, especially in areas such as learning, communication, emotional regulation, and independence. The school cannot guarantee specific developmental progress or outcomes, as progress may vary as per each child's developmental level. Staff will adjust strategies based on the student’s changing needs and will celebrate growth at every level.

Parent/Guardian's Acknowledgement of Program & Policies

StudentScholars is a private institution and does not receive public funding for Special Education services.

The school does not provide 1:1 Educational Assistants (EAs) unless privately arranged and funded by the family.

The school is not equipped to support students requiring full-time 1:1 behavioural support, intensive medical supervision, or highly specialized therapeutic interventions.

Admission and ongoing placement are based on the school’s ability to meet a student’s needs within available resources.

Our programs are offered in an educational setting by special ed teachers. If you require licensed therapy services (e.g., speech, OT, ABA) are offered based on availability and will involve additional fees.

I understand that I may be asked to provide the following to support my child’s success: Psychoeducational assessments or diagnostic , Reports from previous schools, therapists, or specialists reports (if available)

I understand that, at any time during the program, if it is determined that the Centre is unable to adequately meet your or your child's needs, or if the program is no longer a suitable fit, the Centre reserves the right to discontinue the enrollment. In such cases, appropriate notice will be given.

I understand that, in accordance with the Centre’s policies, for missed classes, I am eligible for one credit per subject each month, and I must notify the Centre at least 24 hours in advance of the class to receive the credit. All other classes will be forfeited as we are reserving the spot for your child.

Which programs are you interested in?

Behaviour Therapy Program - 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

Consent & Signature I, the undersigned parent/guardian, confirm that the above information is accurate to the best of my knowledge and give permission for StudentScholars staff to use this information to provide appropriate support. Type Full Name & Date

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StudentScholars:

Special Education Intake Form