ITOWN Cares Intake Form | External Website

Email for Follow-Up Information

Applicant's First Name

Applicant's Last Name

Applicant's Birthdate

Applicant's Gender

Applicant's Address

Campus

I am the applicant's:

Father's First Name

Father's Last Name

Father's Cell Phone

Father's Email

Mother's First Name

Mother's Last Name

Mother's Cell Phone

Mother's Email

Language Spoken at Home

Full Name

Cell Phone

Relationship

Applicant's Primary Disability

Current Medications (Please Include Any Side Effects)

Vision

Glasses Contacts

Vision Corrected with These Aids?

Yes No No Aids Needed

Seizures

Respiratory Problems (None, Asthma, Other):

Heart Problems:

Any Activities where One-On-One Assistance is Needed:

Any Other Medical Concerns:

This Applicant Communicates in the Following Ways:

Non-verbal but vocalizes

Says words

Talks in sentences but may be hard to understand

Talks in sentences and is easy to understand

Uses a communication board

Uses a computer-assisted device

Hearing Problems:

None

Uses a hearing aid

Uses sign language

Cochlear implant

How does the applicant follow directions:

Is unable to follow directions Follows simple one-step directions Follows two-step directions Has no difficulty following directions

What Level does the Applicant Read At?

What Level does the Applicant Write At?

Applicant's Most Recent School Year Placement:

Please Describe Applicant's School Classroom Environment:

Please List Any Sensory Issues (Likes Noise, Sound Sensitive, etc.):

How is the Applicant's Mobility:

Walks independently

Uses a wheelchair

Uses braces

Uses a different assistive device

Does the applicant fall on occasion? If so, under what circumstances?

List any special positioning needs or mobility issues:

Please list any food allergies for the applicant:

Please list any special foods issues (Liquid diet, Soft diet):

Does the applicant have difficulty swallowing?

No Yes Food needs to be cut up Tendency to choke

Does the applicant require Nothing By Mouth?

Yes No

Other Dietary Restrictions:

Food Preferences:

Animal Crackers

Goldfish

Fruit Snacks

Toileting:

Independent

Wears diapers/pull-ups

Bedwetting

Requires assistance

Eating:

Feeds self

Requires assistance

How do you handle this/these behaviors?

What Interests or Activities does the applicant like?

What Interests or Activities does the applicant dislike?

Any Special Fears?

Any Hobbies or Talents?

We Should Contact You If:

Please Provide Any Other Information You Feel is Pertinent:

Service Time Preference

9:00 AM 11:00 AM 1:00 PM

Parent/Caregiver Signature

Clear

Date

Work Entry

FAMILY IN-TAKE FORM

MEDICAL AND FUNCTIONAL HISTORY