Intake Form | Autism Sanctuary

Thank you for your interest in Autism Sanctuary's day program!

This intake and assessment form will take approximately 20 minutes to complete and asks the following information about the applicant (i.e. person in need of services): biographical, psychosocial/demographic, medical, nutrition, behavioral, and current abilities.

PLEASE NOTE: you must upload the following files at the end of the form if applicable: most recent/current Individualized Services Plan (ISP); most recent/current Behavior Intervention Plan; and most recent educational and/or psychological evaluations from within the last 2 years. The application will not be considered to be complete if these documents are not submitted when applicable.

Our team will review your application and attached documents as swiftly as possible. Once reviewed, a member of our team will contact you to set up a time to meet in person for an intake appointment. Should you have any questions, please contact Olivia Bruno.

Your Personal Information

Please fill out this section with contact information of the person completing the form today on behalf of themselves or their loved one.

Your Name(Required)

First Last

Relation to Applicant (i.e. person in need of services)(Required)

Self

Parent/Guardian

Sibling

Other

Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Enter Email Confirm Email

Your Phone(Required)

Preferred Method of Communication(Required)

Phone

Email

Either

Biographical Information of Applicant (i.e. person in need of services)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Race/Ethnicity(Required)

White/Caucasian

Black/African American

Hispanic/Latino

Asian/Pacific Islander

American Indian/Alaska Native

Other

Does the Applicant Live with You(Required)

Yes

No

If not, does the applicant live independently, or in a residential/group facility?

Independently

Residential/Group Facility

Applicant's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Residential/Group Facility

Address of Residential/Group Facility

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person at Facility

First Last

Phone for Facility Contact

Does the applicant currently attend a school, institution, or other day program service?(Required)

Yes

No

Name of Current School/Institution/Day Program

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

At the School/Institution/Day Program:

Number of teachers and/or aides:

Number of other students/participants:

Did the applicant have a 1:1 aide?

Who has legal custody or is the legal guardian of the applicant?(Required)

Applicant (has their own rights)

Parent/Guardian

Not Yet Assigned

Other

If the applicant has a legal guardian/requires legal custody, can you provide legal custody papers/documentation?(Required)

If yes, please provide copies of these documents to the intake appointment.

Yes

No

Not Applicable

Insurance Information

Does the applicant have medical insurance?(Required)

Please email a copy (front & back) of the insurance card to olivia@autismsanctuary.org

Yes

No

Name of Insurance Provider

Policy Information:

Subscriber Name:

Policy Number:

Group Number:

If insurance is through the parent/guardian, by what means do you/they access this health insurance?

If health insurance is through work, please state the company name:

Does the applicant have additional insurance through Medicaid?(Required)

Please email a copy (front & back) of the insurance card to olivia@autismsanctuary.org

Yes

No

Medicaid Number

Physician Information

Name of Primary Care Physician

First Last

Phone of Primary Care Physician

Address of Primary Care Physician

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Physician(s)

Please add more rows as needed by clicking on the + icon next to the "Address" box.

Name

Phone Number

Address

Psychosocial & Demographic Background

Parent/Guardian Information

Include information about the applicant's parents or guardians. Please add more people as needed by clicking on the + icon on the far right.

Name

Age

Who lives it the applicant's residence, other than the applicant?

Please add more people as needed by clicking on the + icon on the far right.

Name

Age

Gender

Relation to Applicant

What is the primary language spoken in the home?

What Community Agencies/Contacts provide services to the applicant?

Please list them below. You can add more people by clicking on the + icon on the far right.

Agency Name

Contact Name

Contact Phone Number

Nature of Service

Additional Details

Do you have any other details that you believe would help us best serve the applicant's needs? If so, please mention them here.

Attachments

You must upload the following files at the end of the form if applicable: most recent/current Individualized Services Plan (ISP); most recent/current Behavior Intervention Plan; and most recent educational and/or psychological evaluations from within the last 2 years. The application will NOT be considered complete until these forms are received by our staff, either by attaching the files to this form or by emailing copies to olivia@autismsanctuary.org.

Please attach the applicant's most recent/current Individualized Services Plan (ISP).

Drop files here or

Max. file size: 128 MB.

Please attach the applicant's most recent/current Behavior Intervention Plan, if applicable.

Drop files here or

Max. file size: 128 MB.

Please attach the applicant's most recent educational and/or psychological evaluations from the past 2 years, if applicable.

Drop files here or

Max. file size: 128 MB.

If you would prefer to submit these documents via email, or are unable to attach the files to this form, please email a copy of these files to olivia@autismsanctuary.org and indicate below which documents you plan to send via email.(Required)

Please select all that apply, or chose "Not Applicable" if you plan to attach all required documents to this form.

Individualized Services Plan

Behavior Intervention Plan

Educational and/or Psychological Evaluations

Not Applicable

Congratulations, you have completed the Autism Sanctuary Client Intake form! Please sign below and click the button to submit.

Privacy Policy and Assurance of Rights(Required)

Thank you for considering Autism Sanctuary for your day program! This Privacy Policy outlines how we collect, use, disclose, and protect the information gathered from users through our intake and comprehensive assessment form. We are committed to safeguarding your privacy and ensuring the security of your personal information.

By using our intake and comprehensive assessment form, you agree to the terms outlined in this Privacy Policy. Please read this document carefully to understand how we handle your information.

1. Information We Collect:
- 1.1. Medical Information:
We may collect information about your/the applicant's medical history, current health status, and any other details relevant to providing you with our services.
- 1.2. Demographic Information:
Demographic information such as age, gender, ethnicity, and occupation may be collected to better understand and meet your specific needs.
- 1.3. Contact Information:
We collect your contact details, including but not limited to your name, address, phone number, and email address, to facilitate communication and provide updates on our programs.
- 1.4. Behavioral Information:
Information about your/the applicant's behavior and preferences is collected to ensure that our services are tailored to your/the applicant's needs.

2. How We Use Your Information:
- 2.1. Service Provision:
We use the collected information to assess whether our program would be a good fit for your/the applicant's needs before beginning the next phase of the application process.
- 2.2. Communication:
Your contact information may be used to communicate with you about proceeding with the application to the day program, contacting you once admitted into the program, and any other updates related to our services.
- 2.3. Legal and Safety:
We may use your information to comply with legal obligations, resolve disputes, and enforce our policies. Your information may also be used in situations where we believe it is necessary to protect the safety and well-being of individuals.

3. Information Sharing:
- 3.1. Third-Party Service Providers:
We may share your information with trusted third-party service providers who assist us in delivering our services. These providers are bound by confidentiality agreements and are required to protect your information.
- 3.2. Legal Requirements:
We may disclose your information if required to do so by law or in response to a valid legal request.

4. Security:
We employ industry-standard security measures to protect your information from unauthorized access, disclosure, alteration, and destruction.

5. Your Choices:
You have the right to review, update, and correct your information. You may also choose to opt-out of certain communications.

6. Changes to the Privacy Policy:
We reserve the right to update this Privacy Policy. Any changes will be communicated to you through the contact information provided.

7. Contact Us:
If you have any questions or concerns regarding this Privacy Policy, please contact us at olivia@autismsanctuary.org.

ASSURANCE OF RIGHTS

By signing this form, you certify that you have received the following assurances:
The individual receiving services has the right to:
1. Be treated with dignity and respect;
2. Be told about their treatment;
3. Have a say in their treatment;
4. Speak to others in private;
5. Have their complaints resolved;
6. Say what they prefer;
7. Ask questions and be told about their rights;
8. Get help with their rights.

By using our client intake form, you acknowledge that you have read and understood this Privacy Policy and Assurance of Rights.

By checking this box and writing by name below, I agree to the policies above.

Name(Required)

Please type your first and last name below to sign this form.

First Last

Date

Intake and Comprehensive Assessment Form

Thank you for your interest in Autism Sanctuary's day program!

Your Personal Information

Biographical Information of Applicant (i.e. person in need of services)

Insurance Information

Physician Information

Psychosocial & Demographic Background

Medical Information

Part 1. General Medical Information

Part 2. Medication Information

Part 3. Hospitalizations

Part 4. Neurological

Part 5. Substance use and Abuse

Part 6. Vision, Hearing, and Dental

Part 7. Additional Specialists

Nutrition

Problem Behaviors

Alternative Treatments/Therapies - Have alternative treatments or therapies been used, currently or in the past?

Current Performance

Food Consumption Skills

Communication Skills

Supervision and Group Settings

Motivating Factors

Additional Details

Attachments

Congratulations, you have completed the Autism Sanctuary Client Intake form! Please sign below and click the button to submit.

Address

Contact

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