Client Information Form printable pdf download

Client Information Form

Client #:_________

Today’s Date:_____________

Client Information Form: Respite Program

Name:__________________________________________

Gender:________________________________

Grade:__________

DOB:____________

Diagnosis:______________________________

Ethnicity:_______________

Language: English Speaking/Spanish Speaking (circle)

Guardian:_______________________________________

Email:_________________________________

Address:______________________________________________________________________________________________

Home Phone:_____________________________

Cell Phone:______________________________

Emergency Contact:__________________________________________________________________________________

Does your child have any of the following (check all that apply)?

Yes

Describe

Visual impairment

Hearing impairment

Seizures

Allergies

Motor impairment

Sensory sensitivities

Other:

Does your child take any medication (list all)? _____________________________________________________________

Referral Information: How did you hear about us? Please include the name and/or agency that

referred you. ___________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Client Information Form