FGA Integrated Program Intake Form
Help us get to know your child.
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Email *
What day may work best  *
Required
How did you hear about our program? *
Today's Date  *
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Parent's Name (First & Last) *
Home Address *
Child's Name (First & Last) *
Child's Nickname *Type N/A if there is no nickname *
Child's Date of Birth *
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Child's Age *
Phone Number *
Child's classification/diagnosis *
School *
Is your child verbal? *
If nonverbal, how does he/she communicate? *Type N/A if your child is verbal *
Does your child have an IEP or a BIP? If so, please explain his/her plan and/or goals. *
Current Medication *
Allergies *
Does your child use an Epi-Pen? If yes, where does he/she keep it? *
Does your child need assistance in the bathroom? *
Medical conditions we should be aware of *
What is your child motivated by? *
My child's strengths include: *
My child is afraid of: *
My child's weaknesses include: *
My child is working on: *
Child's behavior during a transition: *
Does he/she drop? (drop to the floor when trying to walk) *
Does he/she elope? (run away) *
Does your child have any physical limitations? Explain.
Does your child become distracted easily? *
Does your child get frustrated easily?
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Does your child become aggressive? If so, what triggers the aggression? *
Is there any additional information you can provide us with to help your child be successful? *Type N/A if you have nothing else to add.
What are your expectations of our program? *
A copy of your responses will be emailed to the address you provided.
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