Online Client Intake Form-Part 2
MM/DD/YYYY

Scheduling Information

Please fill in the times services are needed for each day of the week:

Health and Medical Information

Communication Level (select all that apply): *
Allergies to (select all that apply):
Seizures (select one):
Assistive Devices (select all that apply):

Diet and Feeding Information

Food: Requires Assistance with Utensils?
Does Food Present a Choking Hazard?
Special Diet: Requires a Feeding Tube?
Beverages: Requires Assistance with Any Cup/Glass?
Independently Requests/Obtains a Beverage?

Balance and Mobility Information

Balance While Standing (select one):
Independent Mobility (select all that apply):

Behavior Information

Behavioral Concerns (select all that apply):

Personal Care

Please select ONE for each category below:

Dressing:
Dental Care:
Toileting:
Medical Administration:
Bathing:
Menses:

Client and Home Information

I Understand and Consent to the following: *
DD/MM/YYYY