INTAKE FORM - MINOR

WE ARE SO GLAD THAT YOU REACHED OUT TO US!

This intake form is to be completed by the caregiver of a minor, or caregiver that has guardianship of an adult. Your input helps us locate services and support in our area that you are seeking. Please provide as much information and detail as possible, so that we will have the background we need to find appropriate resources. The more information we have, the more help we can provide.

If you request a consultation, you will receive a confirmation email of the date and time. Our consultations are done by phone, unless another method is specified.

For information and upcoming events:
www.palmettopartnership.org

Parent/Caregiver Information:

First Name *

Last Name *

Age *

Gender *

Email Address *

Daytime Phone *

Address 1 *

City *

State *

Zip Code *

Would you like to receive emails about events and news for our organization? *

Minor/Dependent Information:

First Name *

Last Name *

Age *

Gender *

Does the child live with you? *

Does the child have a formal diagnosis? *

If yes, what is diagnosis? Please list date and location of evaluation(s). Provide the name of person(s) that conducted the evaluation, if possible.

What is the name and location of the child's Pediatrician? Has the Pediatrician performed any screenings for autism or other developmental delays? *

Does the child have any siblings? Do any of the siblings have disabilities? *

Does the child receive Medicaid/TEFRA? *

Does child have a case worker? If yes, what agency provided the case worker? *

Does child receive ABA services? If yes, what agency provides the ABA services? *

What are the child's favorite activities? *

What frightens or upsets the child? Any phobias or obsessive behavior?

What does the child do when he/she becomes frightened or upset?

Is the child verbally aggressive or destructive at times? If so, please describe the circumstances: *

How does the child react to changes in his or her environment? *

Does the child have a history of physical aggression or self-injurious behavior? If so, please describe circumstances, frequency and how long since you have seen this behavior. *

Does the child attend school or a day program? (Please share name of school/program, the hours he/she attends and if he/she is assisted by a paraprofessional.) Is the child in a self-contained classroom or mainstreamed? *

Current grade in school (if applicable)? *

Does your child have an IEP or 504? Please indicate below: *

Does the child have any health, hygiene, or dietary issues? If yes, please give details: *

Is the child verbal? *

Can the child feed him/herself? *

Does the child have a tendency to wander? *

Is the child toilet trained? *

Is the child currently receiving any services? If yes, list below: *

What services or resources would most benefit the child, or your family? *

How can we help you?

How did you hear about us? *

Would you like to schedule an appointment with a Family Support Consultant? (This consultation will be held over the phone, or at our Resource Center. You will receive an email confirmation with meeting details.) *

If you have requested a consult, please select a date and time for your consultation below: **PLEASE NOTE THAT OUR OFFICE WILL BE CLOSED THROUGH MAY 1, 2024. WE WILL RESUME WEEKLY SERVICES AT THAT TIME.**

Thank you for taking the time to complete the intake form. We are so glad you reached out to us, and hope to provide you with the support and resources that you need.

For information on various agencies and organizations that provide disability services and resources, please go to the RESOURCE LINKS TAB on our website: www.palmettopartnership.org

REMEMBER... YOU ARE NOT ALONE!

The mission of THE PALMETTO PARTNERSHIP of All 4 Autism is to increase the quality of life of those with disabilities, and their families, by providing free resources, support and advocacy services, while actively seeking opportunities to partner with others and serve as ambassadors of goodwill in our community. We are a grassroots organization, and all of our services are free and open to the public.

WANT TO HELP SUPPORT OUR EFFORTS? Please consider becoming a PALMETTO PARTNER through our recurring giving program. For more information: www.palmettopartnership.org