Intake Review - Midland Kru Day Program

Day Program Intake Form

Completed by:

Date

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1.1 Associate Information
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First Name

Last Name

Preferred / Other Name(s)

Date of Birth

Sex

Ethnicity (optional)

Associate’s Legal Guardian’s Name

Associate Resides With

If Other, specify

Details of Living Arrangements (if necessary)

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1.2 Family Information Continued
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Mother – First Name

Mother – Last Name

Mother – Email

Mother – Address

Mother – City / Town

Mother – Zip Code

Mother – Phone (Home)

Mother – Phone (Mobile)

Mother – Contact Preference

Mobile Home

Father – First Name

Father – Last Name

Father – Email

Father – Address

Father – City / Town

Father – Zip Code

Father – Phone (Home)

Father – Phone (Mobile)

Father Contact Preference

Mobile Home

Care Giver – Name

Relationship

Care Giver – Email

Care Giver – Address

Care Giver – City / Town

Care Giver – Zip Code

Care Giver – Phone (Home)

Care Giver – Phone (Mobile)

Care Giver Contact Preference

Mobile Home

Background: A brief description your associate’s education, health, routine. Include all current medications your associate takes and dosage.

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1.3 Attendance Request
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Days Requesting to Attend ($65/day)

Monday Tuesday Wednesday Thursday

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1.4 Support Network
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A. Describe any current community, family / friends, agency support the family is currently receiving or wishes to receive.

B. Family Physician / Nurse Practitioner (if applicable)

Physician Phone

Emergency Contact 1 – Name

Emergency Contact 1 – Relationship

Emergency Contact 1 – Phone

Emergency Contact 1 – Address

Emergency Contact 2 – Name

Emergency Contact 2 – Relationship

Emergency Contact 2 – Phone

Emergency Contact 2 – Address

Emergency Contact 3 – Name

Emergency Contact 3 – Relationship

Emergency Contact 3 – Phone

Emergency Contact 3 – Address

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2.1 Identification of Supports, Services and /or Assistance
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Areas of Development

Likes & Dislikes

Hobbies / Interests (participation & reasons if not)

Community Activities (current)

Diagnosis / Assessments / Observations

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3.1 Skills Profile
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Does the associate have a delay or challenge in any of the following areas? According to normal development for his or her age.

Social Situation / Interactions

Yes No

Brief Description

Expressive Language

Yes No

Brief Description

Receptive Language

Yes No

Brief Description

Personal Safety

Yes No

Brief Description

Mobility

Yes No

Brief Description

Personal Care

Yes No

Brief Description

Anxiety

Yes No

Brief Description

Inappropriate Acting Out

Yes No

Brief Description

Sensory Sensitivities

Yes No

Brief Description

Self-harm / Harm to Others

Yes No

Brief Description

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3.2 Anxiety / Social / Sensory Profile
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Does the associate have a challenge in any of the following areas? Please indicate severity.

Changes to activities / schedules

Yes No

Description (be specific)

Specific sounds / textures / tastes

Yes No

Description (be specific)

Socializing with others / crowds

Yes No

Description (be specific)

Inappropriate acting out

Yes No

Description - (ex. mild, moderate, severe)

Being touched

Yes No

Description - (ex. mild, moderate, severe)

Sharing / ownership

Yes No

Description - (ex. mild, moderate, severe)

Awareness of danger / potential harm

Yes No

Description - (ex. mild, moderate, severe)

Interventions Utilized

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3.3 Health / Medical / Personal Care Profile
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Does the associate have challenges in any of the following areas? (Age appropriate)

Walking / Mobility

Yes No

Description (be specific)

Gross Motor (e.g., catching ball)

Yes No

Description (be specific)

Fine Motor (e.g., buttons / holding pencil)

Yes No

Description (be specific)

Taking Medication

Yes No

Description (be specific)

Health / Medical / Personal Care Comments

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3.4 Communication Profile
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Does the associate have challenges in any of the following areas? (Age appropriate)

Following simple directions

Yes No