Intake Form

First name

Last name

Phone

Child & Family Context

How old is your child?

When did you first start having concerns?

What prompted you to reach out now?

Who lives in the home, and who is most involved day-to-day?

Diagnosis & Evaluations

Has your child received a diagnosis? If so, when and by whom?

What explanations were given to you?

What felt clear—and what felt confusing or alarming?

Current Supports

What therapies is your child currently receiving (if any)?

How often, and how does your child seem to respond?

What feels helpful? What feels heavy or unclear?

School / Learning Environmen

Is your child in school or daycare?

Do you feel supported by the school?

Are there upcoming meetings or decisions you’re worried about?

Daily Life & Regulation

How are transitions, sleep, eating, and emotional regulation?

What parts of the day feel hardest?

What moments actually feel good or easy?

Parent Experience

What feels most overwhelming right now?

What are you most afraid of getting wrong?

What would feeling “supported” look like to you?