Intake Child - Wuttkes' Infinite Potential Institute

Intake Form for Children

Confidential Personal History for Children and Young Adults

A copy of this form will be sent to the email address you provide below as well as to [email protected] after it is finalized.

Step 1 of 9

Today’s Date:

Family Name:(Required)

Child’s Name:(Required)

Contact Email Address:(Required)

Phone:(Required)

Address:(Required)

Age

Handedness:

Gender

Birthdate:

School:

Grade:

Completed by:

Referred by:

Mother’s Address (if different from above):

Father’s Address (if different from above):

Parent or Guardian (name):

Parent or Guardian (signature):(Required)

Accepted file types: jpeg, jpg, gif, png, pdf, Max. file size: 1 GB.

Has your child been previously diagnosed as having a specific disorder?

Has your child received any special education or special therapy?

Have there been any specific events or traumas linked with the onset of your child’s difficulties?

Is your marital/familiar situation stable and positive at this time?

What, if any, stresses are affecting your family at this time?

Which language(s) is(are) spoken at home?

Are there other individuals or family members living at home?

EDUCATION

In general, how would you describe your child’s experience/learning at school from kindergarten to the present time?

How did your child adapt to the first day(s) at school or pre-school?

Mostly positive

Mixed

Mostly negative

How old was he/she?

How much time did he/she attend (per week)?

Please give us more detailed information about any difficulties your child encountered in school beginning with the earliest experience.

Has there been special assistance or tutoring given outside the school system?

Yes

Please describe:

BEHAVIOR/CHARAKTER

How would you describe your child?

What are your child’s strengths?

What are your child’s weaknesses?

Have there been any specific behavior problems in the course of your child’s development?

What kind of interests and activities does your child have (hobbies, sports, clubs)? Please list them in order of preference beginning with the favorite activity.

How would you describe your child’s social adjustment - With peers?

How would you describe your child’s social adjustment - With adults?

Please add any other comments you might have regarding your child’s behavior and character:

GOALS

What are your goals for your child’s program? Please be as specific as possible.

ADDENDIUM

If you are temporarily the child’s primary caregiver, please add:

The relationship you have with the child:

Any additional comments you feel would be helpful:

Intake Form for Children

Confidential Personal History for Children and Young Adults

FAMILY INFORMATION

1st Child Information

Section Break

2nd Child Information

Section Break

3rd Child Information

Section Break

4th Child Information

Section Break

5th Child Information

Section Break

6th Child Information

Section Break

7th Child Information

Section Break

8th Child Information

Section Break

FAMILY BACKGROUND

PREGNANCY

LABOR AND DELIVERY

Section Break

ADOPTION

Section Break

INFANCY

CHILDHOOD ILLNESSES

SENSORI-MOTOR DEVELOPMENT

VISUAL DEVELOPMENT

AUDITORY DEVELOPMENT

SPEECH AND LANGUAGE DEVELOPMENT

PREVIOUS ASSESSMENTS

EDUCATION

BEHAVIOR/CHARAKTER

GOALS

ADDENDIUM

Section Break

Wuttke Infinite Potential Institute

© Infinite Potential Institute LLC

Wuttke Infinite Potential Institute

© Infinite Potential Institute LLC