Intake and Comprehensive Assessment Form Intake and Comprehensive Assessment Form Step 1 of 10 10% 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 InformationPlease 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required) Male Female Non-binary Prefer not to answer Other 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Name of Residential/Group FacilityAddress of Residential/Group Facility Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Contact Person at Facility First Last Phone for Facility ContactDoes the applicant currently attend a school, institution, or other day program service?(Required) Yes No Name of Current School/Institution/Day ProgramPhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands 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? Add RemoveWho 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 InformationDoes the applicant have medical insurance?(Required)Please email a copy (front & back) of the insurance card to casey@autismsanctuary.org Yes No Name of Insurance ProviderPolicy Information:Subscriber Name:Policy Number:Group Number: Add RemoveIf 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 casey@autismsanctuary.org Yes No Medicaid NumberPhysician InformationName of Primary Care Physician First Last Phone of Primary Care PhysicianAddress of Primary Care Physician Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Other Physician(s)Please add more rows as needed by clicking on the + icon next to the "Address" box.NamePhone NumberAddress Add Remove Psychosocial & Demographic BackgroundParent/Guardian InformationInclude information about the applicant's parents or guardians. Please add more people as needed by clicking on the + icon on the far right. NameAge Add RemoveWho 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. NameAgeGenderRelation to Applicant Add RemoveWhat 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 NameContact NameContact Phone NumberNature of Service Add Remove Medical InformationPart 1. General Medical InformationPlease list all previous and current psychiatric and/or developmentally-related diagnoses/concerns.Click on the + icon on the far right to add more items to the list. Add RemovePlease list all previous and current medical diagnoses/concerns.Click on the + icon on the far right to add more items to the list. Add RemovePlease list the diagnosing physician(s) or other professionals.Add more people by clicking on the + icon on the far right.NameSpeciality/Area of Expertise Add RemovePlease list the type of instrument, mechanism, or manner (e.g. Eligibility Team, DSM diagnosis, etc.) in which the applicant was diagnosed.Click on the + icon on the far right to add more items to the list. Add RemoveDoes the applicant require specific medical equipment and/or treatments? For example, an insulin pump, feeding tube, inhaler, etc.(Required) Yes No If yes, please list these below.Click on the + icon on the far right to add more items to the list. Add RemoveDoes the applicant have any known allergies?(Required) Yes No If yes, please list these below.Click on the + icon on the far right to add more items to the list.AllergenReaction to allergenTreatment for allergyFormally tested or suspected? Add RemovePart 2. Medication InformationPlease list all information for each medication that is currently taken.Click on the + icon on the far right to add more items to the list.Medication nameStart dateDosagePurposeHas it been effective? Add RemoveDoes the applicant use any topical medications (i.e. ointments, creams)(Required) Yes No If yes, please list them below.Click on the + icon on the far right to add more items to the list.Medication nameStart dateDosagePurposeHas it been effective? Add RemovePlease list other medications that have been prescribed but are no longer being administered.Click on the + icon on the far right to add more items to the list.Medication nameStart dateEnd dateDosagePurposeWas it effective? Add RemovePart 3. HospitalizationsHas the applicant had any hospitalizations within the past five years?(Required) Yes No Please list hospitalizations below.Click on the + icon on the far right to add more items to the list.Hospital NameDateReason Add RemoveHas the applicant had any surgeries?(Required) Yes No Please list surgeries below.Click on the + icon on the far right to add more items to the list.Hospital NameDateReason Add RemovePart 4. NeurologicalDoes the applicant have a history of seizures?(Required) Yes No Age of OnsetDate of Last Seizure Month Day Year How often does a seizure occur, and how long does it last?Please describe what the seizure activity looks like.Please describe any other neurological concerns/diagnoses, if applicable.Date of Last EEG, MRI, or CT Scan, if Applicable. Month Day Year Date of Last Neurologist Visit Month Day Year Neurologist Name First Last Neurologist Phone NumberPart 5. Substance use and AbuseDoes the applicant have any history of substance use or abuse, including co-occurring mental health and substance abuse disorder? If yes, please explain.Part 6. Vision, Hearing, and DentalDoes the applicant wear glasses/contacts?(Required) Yes No How often are these glasses/contacts worn?What concerns do these glasses/contacts address (i.e. nearsightedness, farsightedness, etc.)?Does the applicant have any other vision problems?(Required) Yes No Unsure If yes, please explain:Date of Last Eye Exam (if applicable) Month Day Year Seen by: Ophthalmologist Optometrist Other Physician's Name First Last Physician's Phone NumberDoes the applicant have any problems with hearing?(Required) Yes No Unsure If Yes, Please Explain:Does the applicant wear a hearing aid?(Required) Yes No How often is this hearing aid worn?Does the applicant have a history of ear infections?(Required) Yes No Unsure If Yes, Please Explain:Date of Last ENT Exam (if applicable) Month Day Year Physician's Name First Last Physician's Phone NumberAre there any problems with the applicant's current condition of teeth?(Required) Yes No Unsure If yes, please explain:Date of Last Dental Exam: Month Day Year Please list the Applicant's Past Dental Procedures Below:Add more procedures by clicking on the + icon on the far right.ProcedureDate of procedure (mm/dd/yyyy) Add RemovePart 7. Additional SpecialistsPlease include additional specialists (such as cardiologist, urologist, orthopedics, etc.) below:Add additional people by clicking on the + icon on the far right.Physician's NameSpecialtyPhone NumberReason for Appointment Add Remove NutritionCurrent Weight(Required)Current Height(Required)Dietary Preferences(Required)Check all that apply. No restrictions Chopped food only Pureed food only Low fat Low protein Gluten free Other If you have selected "other," please describe the applicant's dietary preferences below:Please describe any feeding problems below:This can include, but is not limited to: chewing concerns, choking risk, swallowing concerns, eating too quickly, vomiting, food aversions, etc.Does the applicant take any nutritional supplements?(Required) Yes No Unsure If yes, please list these supplements below:Add more items by clicking on the + icon on the far right. Add Remove Problem BehaviorsList each problem behavior that the applicant displays and please describe it in detail. Please list in the order of most concerning to least concerning to yourself or other caretakers.Add more behaviors by clicking on the + icon on the far right.BehaviorDescriptionOccurrence (Daily/Weekly/Monthly)Damage to Self/Others/Property Add RemoveFor the behavior listed above as being of the greatest concern, what would be the estimated severity of this behavior? Minor Moderate Severe Life Threatening In what settings do problem behavior(s) most occur? Home School Community Other If you selected "other," please describe:How long has the applicant been engaging in problem behavior(s)? Within past 6 months More than 6 months, but less than a year More than 1 year, but less than 5 years More than 5 years, but less than 10 years More than 10 years When are problem behaviors most likely to occur?Please select all that apply. When the applicant is left alone or unattended When a lot of people are around, or in an overstimulating environment When demands are being placed on the applicant During mealtime, dressing, or bathing When the applicant can not have something that they want During morning During afternoon During evening Other If you selected "other," please explain:Are there any situations or environments in which problem behaviors rarely or never occur?How do others (such as parents, staff, caregivers) typically respond when the applicant engages in these kind of behaviors?Has the applicant ever been sent to the hospital to treat an injury resulting from a problem behavior?(Required) Yes No If yes, please explain:Has the applicant ever injured someone in such a way that they required medical treatment?(Required) Yes No If yes, please explain:Has the applicant ever been hospitalized to create a treatment plan for one of these problem behaviors?(Required) Yes No If yes, please explain:Please also bring a copy of this treatment plan with you to the intake assessment, if possible.Is there a formal program or intervention protocol currently being used for problem behaviors?(Required)If yes, please bring this program/protocol with you to the intake assessment. Yes No How long has this program/protocol been in place?How would you estimate the general trend of behaviors over the past year?(Required) Increasing (behavior getting more severe) Stable (about the same) Decreasing (behaviors are improving) Does the applicant display aggressive behavior toward staff or peers?(Required) Yes No If yes, please explain:Was the onset of problem behavior(s) believed to be associated with a specific event or series of events?(Required) Yes No Unsure If yes, please explain:Have the following procedures/protocols ever been used to treat the problem behavior(s)?Please select all that apply. Restraint Protective Equipment (such as gloves, helmet) Positive Reinforcement Time Out Corporal Punishment, spanking, etc. Other For restraint, please describe the procedure/protocol:Which problem behavior was the procedure/protocol meant to treat?Start Date Month Day Year Still Used? Yes No End Date Month Day Year Degree of Success Poor Fair Good Excellent Please describe the type of protective equipment used:Which problem behavior was the equipment meant to treat?Start Date Month Day Year Still Used? Yes No End Date Month Day Year Degree of Success Poor Fair Good Excellent For positive reinforcement, please describe the procedure/protocol:Which problem behavior was the procedure/protocol meant to treat?Start Date Month Day Year Still Used? Yes No End Date Month Day Year Degree of Success Poor Fair Good Excellent For time out, please describe the procedure/protocol:Which problem behavior was the procedure/protocol meant to treat?Start Date Month Day Year Still Used? Yes No End Date Month Day Year Degree of Success Poor Fair Good Excellent For corporal punishment/spanking, please describe:Which problem behavior was the procedure/protocol meant to treat?Start Date Month Day Year Still Used? Yes No End Date Month Day Year Degree of Success Poor Fair Good Excellent If you selected "other," please describe:Which problem behavior was the procedure/protocol meant to treat?Start Date Month Day Year Still Used? Yes No End Date Month Day Year Degree of Success Poor Fair Good Excellent Alternative Treatments/Therapies - Have alternative treatments or therapies been used, currently or in the past?If yes, please state the name of the prescribing physician/professional and start/end dates for any of the applicable categories below. If no, please leave this section blank.Gluten-Free and/or Casein-Free DietPlease list below only if being used as an alternative treatment for behaviors. If the applicant is gluten/casein free solely because of allergies and/or specific dietary restrictions, please select the "gluten free" option under the "dietary preferences" question on the prior "Nutrition" page of this form.Prescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add RemoveHyperbaric Chamber TreatmentPrescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add RemoveChelationPrescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add RemoveSensory IntegrationPrescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add RemoveMusic TherapyPrescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add RemoveDance TherapyPrescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add RemoveOtherTherapy/Intervention TypePrescribing Physician/Professional NameDate StartedDate Ended (if applicable) Add Remove Current PerformanceToileting Skills(Required)Please score the items below using the number that most closely describes the applicant's ability: 1 - Cannot perform skills independently or correctly; 2 - Requires much assistance to perform skill correctly; 3- Requires some assistance to perform skill correctly; 4 - Performs skill independently and correctly. If the skill is not applicable, write "NA."Has bowel movement in toiletUrinates in toiletUses pull ups/diapers during day Add RemoveMotor Skills(Required)Please score the items below using the number that most closely describes the applicant's ability: 1 - Cannot perform skills independently or correctly; 2 - Requires much assistance to perform skill correctly; 3- Requires some assistance to perform skill correctly; 4 - Performs skill independently and correctly. If the skill is not applicable, write "NA."Walks without assistanceUses wheelchairUses bracesUses walker Add RemoveFood Consumption SkillsFor the next section, please select the description that best fits the applicant's current performance.Throws/Plays with Food(Required) Consistently Sometimes Never Needs to be Fed(Required) Consistently Sometimes Never Drinks from a Cup(Required) Consistently Sometimes Never Properly Uses a Spoon(Required) Consistently Sometimes Never Properly Uses a Fork(Required) Consistently Sometimes Never Communication SkillsFor the next section, please select the description that best fits the applicant's current performance.Speaks Freely and Easily(Required) Consistently Sometimes Never Talks Mainly in Phrases(Required) Consistently Sometimes Never Uses Single Words(Required) Consistently Sometimes Never Communicates with Gestures(Required) Consistently Sometimes Never Uses Sign Language(Required) Consistently Sometimes Never Communicates with Pictures(Required) Consistently Sometimes Never Writes/Prints(Required) Consistently Sometimes Never Understands Simple Questions(Required) Consistently Sometimes Never Follows Simple Commands/Instructions(Required) Consistently Sometimes Never Can Imitate a Model(Required) Consistently Sometimes Never Uses Assistive Communication Device (AAC)(Required) Consistently Sometimes Never If using Assistive Communication Device, please provide the name of the device:Supervision and Group SettingsWhat Frequency/Type of Supervision is Required?(Required) Constant (1-on-1) Individualized (small group) Large group Fully independent Can the applicant be left alone for brief periods of time?(Required) Yes No Does the applicant need continuous monitoring, but still works well in a group?(Required) Yes No Unsure Not Applicable Does the applicant appear to enjoy social interaction?(Required) Yes No Please describe why you selected yes or no above:Motivating FactorsPlease list the applicant's favorite motivating foods, items, and activities below. Favorite FoodsAdd more items by selecting the + icon on the far right. Add RemoveFavorite Toys/ItemsAdd more items by selecting the + icon on the far right. Add RemoveFavorite ActivitiesAdd more items by selecting the + icon on the far right. Add RemoveFavorite Kinds of Social InteractionAdd more items by selecting the + icon on the far right. Add RemoveAre there specific items, activities, places, or environments that the applicant has a strong aversion to? If yes, please list them here.Add more items by selecting the + icon on the far right. Add Remove Additional DetailsDo you have any other details that you believe would help us best serve the applicant's needs? If so, please mention them here.AttachmentsYou 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 casey@autismsanctuary.org. Please attach the applicant's most recent/current Individualized Services Plan (ISP). Drop files here or Select files Max. file size: 64 MB. Please attach the applicant's most recent/current Behavior Intervention Plan, if applicable. Drop files here or Select files Max. file size: 64 MB. Please attach the applicant's most recent educational and/or psychological evaluations from the past 2 years, if applicable. Drop files here or Select files Max. file size: 64 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 casey@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 casey@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 MM slash DD slash YYYY Δ Address 2860 Pea Ridge Road, Charlottesville, VA 22901 Contact casey@autismsanctuary.org Subscribe First NameJohnLast NameSmithYour emailjohnsmith@example.comSubmit Copyright © 2025 All Rights Reserved. FollowFollow
