Intake Form

Today's Date:
Completed By:
Child's Name:*

Age: years
If child is under one year please give us their age in months:
Address*


Country

Date of Birth:
SEX:
MaleFemale
Parent A's Name*:
Parent A's Date of Birth:
Parent A's Address: (Leave blank if same as child)
Country:
Home Phone*:
-
Cell Phone*:
-
E-mail:
SKYPE ID:
Line of work:
Relationship to child: BiologicalAdoptiveStepFosterOther
Parent B's Name:
Parent B's Date of Birth:
Parent B's Address: (Leave blank if same as child)
Country:
Home Phone*: -
Cell Phone*: -
E-mail:
SKYPE ID:
Line of work:
Relationship to child:
BiologicalAdoptiveStepFosterOther
Contact Information
Preferred Contact Number:*
Emergency Contact Name:
Relationship:
Phone Number:







Primary care doctor:
Doctor's Phone Number:
Doctor's Fax Number:
Doctor's Address




Country



Responsible Party Information


Name
Signature
I understand payment is due at the time of services are rendered. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.


Is your child registered with NDIS (National Disability Insurance Scheme)? *
YesNo

Other funding arrangements:
How did you hear about Cloud Nine Therapy? *
If you select other, please describe.
If you were referred, who referred you to Cloud Nine Therapy?
Pediatrician/Family PhysicianOccupational TherapistSchoolFamily memberFriendOther
If you select other, please describe.
Name of person who referred you:
Referral Address:





Country
Cloud Nine Therapy has my permission to send a thank you letter to my referral source indicating my child has been seen for an evaluation:
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Areas of Concern & Goals


My primary area(s) of concern at this time is (check all that apply):
FeedingSensorySpeech/LanguageSocial/EmotionalDietary
Please describe in your own words, what your current concerns for your child are at this time (i.e. related to academics, activities of daily living, relationships, sensory, speech, motor, play, feeding):
How can we be most helpful to you and your child?
What are your goals for your child's program? Please be as specific as possible. Goal 1:
Goal 2
Goal 3
Goal 4
Goal 5

Courtesy : https://www.spdstar.org