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Initial Intake Form
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Initial Intake Form
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General Resources
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Initial Intake Form
Jeremy Lyngdoh
2021-12-03T09:42:45-05:00
Initial Intake Form
Initial Intake Form
Demographics
Date of Entry
*
Name
*
Name
First
First
Last
Last
Date of Birth
*
Age (in years)
Gender
Male
Female
Race
Caucasian
African American
Asian
Other (please specify)
Other (please specify)
Ethnicity
Hispanic
Non-Hispanic
Primary Language
English
Spanish
Other (please specify)
Primary Language
Primary Communication Mode
Verbal
Augmentative/Alternative
Education Level
Less than high school
Completed high school
Other (please specify)
Education Level
Currently employed?
Yes
No
Additional Information
Contact Information
Home Phone Number
*
Cell Phone Number
Email
Additional Information
Disability Status
IQ Range
< 50
51–70
> 70
Severity
Mild
Moderate
Severe
Profound
Presence of Disabilities
Intellectual Disability
Autism Spectrum Disorder
Mental Health Disorder
Speech/Language Impairment
Low Vision/ Blindness
Deaf/ Hard of Hearing
Other Conditions (please specify)
Other Conditions (please specify)
Co-existing Chronic Conditions (please provide ICD codes, if applicable)
Visual
Code
Additional Information
Housing Status
Address
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Location
Urban
Rural
Suburban
Housing Type
Family home
Group home
Nursing home
Other residential facilities (please specify)
Housing Type
Length of Residence (in years)
*
Additional Information
Support Needs
Area of Support Needed
Entrances & exits
Steps and stairways
Kitchen
Bathroom
Living room
Bedroom
Throughout the house
Other (please specify)
Other (please specify)
Type of technology currently in use
Visual
Code
Type of technology requested
Visual
Code
Briefly described any challenges or barriers experienced
Visual
Code
Additional Information
Documentation Upload
Please upload relevant documents (for e.g.- consent form):
Drop a file here or click to upload
Choose File
Maximum upload size: 516MB
Project Status
Date
Project Status
Eligible
Non-eligible
Enrolled
Cancelled
Completed
Project Phase
Assessment
Technology selection
Implementation
Training
Maintenance
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