Assessment Intake Form

Client Information

First name

Last name

Date of birth

Gender

First name

Last name

Phone number

Email address

Relationship to child

Address

Can we contact you by phone, email, and voicemail?

Yes No

Is your student available evenings and weekends for assessment?

Yes No

When were you planning to begin the assessment process?

Have you completed a 15 minutes consult with Taras?

Has the child previously received specialized supports at school?

Yes No

Does the child have a previous diagnosis?

Yes No

Does the child have any pre-existing medical conditions?

Is there anything else regarding the child's medical history that we should be aware of?

Does the child have any siblings?

Yes No

Have any of the siblings experienced similar challenges?

Is the child currently attending school?

Yes No

If yes, what grade or level?

Is there anything else regarding the child's personal history that we should be aware of?

Describe the reasons for seeking assessment.

Describe any goals or outcomes you hope the child to achieve from assessment.

Is there anything else you would like to tell me about your child?