Intake Form

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    Child's Information

    Name

    Date of Birth

    Gender

    MaleFemale

    Parents' Information

    Name

    Home Phone

    Cell Phone

    Work Phone

    Email Address

    Name

    Home Phone

    Cell Phone

    Work Phone

    Email Address

    Other Caregiver's Name

    Home Phone

    Cell Phone

    Work Phone

    Email Address

    Siblings

    Name

    Age

    Gender

    MaleFemale

    Any special needs?

    Yes

    If yes, please list diagnosis:

    No

    Name

    Age

    Gender

    MaleFemale

    Any special needs?

    Yes

    If yes, please list diagnosis:

    No

    Name

    Age

    Gender

    MaleFemale

    Any special needs?

    Yes

    If yes, please list diagnosis:

    No

    Child's Home Address

    Who resides in the home with the child?

    Strengths and Concerns

    Describe your child's strengths:

    How old was your child when you FIRST had concerns about development?

    CURRENT parent concerns (mark all that apply)

    Late Development

    Regression/Loss of Skills

    Challenging Behavior

    Tantrums
    Aggression
    Self-injurious behavior
    Property destruction
    Other

    Language/Communication

    Following Directions

    Social Interactions

    Peer Interactions
    Sibling Interactions
    Interactions with Adults/Teachers
    Other

    Daily Living Skills

    Toileting
    Handwashing
    Dressing
    Showering
    Eating
    Other

    Community Inclusion

    Participation in group activities such as sports or birthday parties
    Family outings (e.g., eating at a restaurant, visiting a playground, visiting a store)
    Tolerating a doctor / dentist visit
    Tolerating a hair cut
    Other

    Additional Concerns

    School Information

    Has your child’s teacher / school informed you they have concerns?
    Yes

    Challenging behavior
    Language / Communication
    Following Directions
    Social interactions

    Peer Interactions
    Interactions with other Adults/Teachers

    Hyperactivity
    Distractibility
    Difficulty completing homework
    Additional comments

    No

    Child's School/Daycare

    Phone
    Address
    Case Manager/Director
    Teacher/Classroom

    Does your child have an IEP? Please upload

    Diagnostic Information

    Has your child received a diagnosis?
    Yes

    Diagnosis
    Date received
    Who made the diagnosis?
    Family history of this diagnosis (or related)?
    Please upload a copy of the diagnostic report

    No

    Medical Information

    Pediatrician

    Phone

    Does your child have any medical conditions?
    Yes

    Does your child have any allergies?
    Yes

    No

    Does your child require an EpiPen?
    Yes
    No

    Current Treatment/Service History

    Please list ALL current medications and supplements with dosage information:
    Name of medication:
    Dosage:
    Name of medication:
    Dosage:
    Name of medication:
    Dosage:

    Please list ALL treatment/services your child currently receives:

    SERVICE




    PROVIDER




    FREQUENCY




    Please list all services that your child received in the past:

    SERVICE




    PROVIDER




    Start/End Dates




    Parent/Caregiver Training

    Gold Coast Children’s Center requires each family to participate in parent / caregiver training. Please describe some areas you feel would be helpful to address through parent training.

    Child Preferences

    Please list your child's favorites:
    Food
    Toys
    Drinks
    Activities
    Characters
    Shows
    Other preferred items/activities

    Insurance

    Gold Coast Children’s Center, LLC is not in-network with any insurance companies and is therefore considered an “out-of-network” provider. With your permission we will inquire about your current benefits and out of network reimbursement. A quote of benefits and/or authorization does not guarantee payment. We are happy to provide you with the information to assist you in seeking reimbursement from your insurance company; but please be reminded that every family is solely responsible for timely payment for services rendered, and this is not contingent or conditioned upon getting reimbursed by your insurance company.

    Insurance Company
    Phone #
    Name of Policyholder
    Date of Birth
    Employer
    Relation to Child
    Policy #
    Group #

    Upload front of insurance card
    Upload back of insurance card

    How did you hear about Gold Coast Children's Center? (Check all that apply)
    Friend/Family Member

    Doctor/Professional serving my child

    Publication

    Social Media (e.g. Facebook group)

    Google search

    Other

    Intake request completed by
    Name

    By submitting this form you acknowledge all information is correct to the best of your knowledge.