EmailMe Form - HEIDI FRIEDMAN - ADVOCACY INTAKE SHEET

DATE OF INTAKE

MM / DD / YYYY

NAME OF CHILD

First Last

DATE OF BIRTH

MM / DD / YYYY

GRADE / SCHOOL

TOWN

MOTHER

First Last

FATHER

First Last

ADDRESS

HOME PHONE

### - ### - ####

MOM'S CELL PHONE

### - ### - ####

DAD'S CELL PHONE

### - ### - ####

E-MAIL ADDRESS

MEDICAL INSURANCE

BOTH PARENTS WORKING?

OFFICIAL DIAGNOSIS

SYMPTOMS

DOCTOR - HOSPITAL / CLINIC

DATE OF MOST RECENT REPORT

MM / DD / YYYY

ARE YOU GETTING A MORE RECENT REPORT?

AGE CHILD FIRST DIAGNOSED

OBSERVATION PERFORMED? IF YES, WHO PERFORMED OBSERVATION AND WHEN?

DO YOU NEED AN OBSERVATION (YES / NO)?

EDUCATIONAL TESTING PERFORMED? IF YES, WHO PERFORMED TESTING?

OTHER PRIVATE TESTING PERFORMED

WHO TESTED AND WHEN?

ON AN IEP OR 504 (YES/NO)? IF YES, SERVICES RECEIVING

INTEGRATED CLASS (YES/NO)?

AIDE (YES/NO)?

CURRENT RATIO --- 1:

ABA?
IF YES, PLEASE LIST # OF HOURS /WEEK, LOCATION, NAME OF PROVIDER AND IF GROUP OR INDIVIDUAL

OT?
IF YES, PLEASE LIST # OF HOURS /WEEK, LOCATION, NAME OF PROVIDER AND IF GROUP OR INDIVIDUAL

PT?
IF YES, PLEASE LIST # OF HOURS /WEEK, LOCATION, NAME OF PROVIDER AND IF GROUP OR INDIVIDUAL

SPEECH?
IF YES, PLEASE LIST # OF HOURS /WEEK, LOCATION, NAME OF PROVIDER AND IF GROUP OR INDIVIDUAL

SOCIAL GROUP?
IF YES, PLEASE LIST # OF HOURS /WEEK, LOCATION, NAME OF PROVIDER AND HOW MANY TYPICAL V/ IEP

OTHER SERVICES RECEIVING

HAPPY WITH IEP? IF NOT, WHAT DO YOU FEEL IS MISSING?

DOES A DOCTOR PRESCRIBE THE SERVICE(S) YOU ARE SEEKING?

SPECIAL EDUCATOR / CONTACT PERSON AT SCHOOL

RECEIVING ANY PRIVATE SERVICES (YES / NO)?
IF YES, SERVICES RECEIVING

NOTES