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Participant Intake
This form is designed to capture and record initial Participant information to determine if the services of Arms Wide Open are a match for the potential client.
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* Indicates required question
What is your child's name?
*
Your answer
What is the parent/guardian name(s)?
*
Your answer
What is your address?
Your answer
Will you be using grant/scholarship or private payment?
Your answer
What is your child's current age?
*
Your answer
What is a good contact phone number?
*
Your answer
Does your child demonstrate aggressive behaviors?
*
Yes
No
What is the nature of your child's difference?
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Your answer
Does your child have any allergies?
*
Your answer
Does your child require assistance with sanitary needs?
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Yes
No
Does your child require assistance with eating?
*
Yes
No
What are some interest/hobbies your child has?
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Your answer
Is your child non-verbal or limited to ASL?
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Yes
No
Will your child require medication while in the care of Arms Wide Open?
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Yes
No
Is your child wheel-chair bound?
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Yes
No
What are some things we may need to be aware of (outbursts, seizures, drooling, etc)?
*
Your answer
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