Intake Form - Part 1 of 2
Print out, fill in the requested information, make a copy for your files, and send to me as part of your Healthy Kids Advocacy Packet.
Mail to: Healthy Kids, 79 Elmore Street, Newton, MA 02459
Please call if you have questions: 617-965-9637
Child's Name:______________________________________
Child's Age & Birthday:___________________________________
Child's Grade Level: _____________________________________
Child's Address: _________________________________________
__________________________________________________________
Mother's Name:______________________________________________
Home Phone:______________________Business Phone:_______________________
Email: __________________________Cell Phone:________________________
Mother's Address if different than child:
____________________________________
____________________________________
Father's Name: ________________________________________
Home Phone: _____________________Business Phone:____________________
Father's Address if different than child:
_______________________________________
_______________________________________
Siblings: Names and Ages
_______________________________________
_______________________________________
Other significant family members:
_______________________________________
_______________________________________
Child's School Name: _______________________________________
School Address: ____________________________________________
____________________________________________________________
School Phone: ___________________
School Website:_________________
The child has an Individualized Health Plan? Yes ( ) No ( )
The child has a Section 504 Plan? Yes ( ) No ( )
The child has an IEP? Yes ( ) No ( )
Child's Health Issues:
____________________________________________________
____________________________________________________
Child's Medications: ____________________________________
____________________________________________________
Child's Educational Issues:
____________________________________________________
____________________________________________________
____________________________________________________
Please fill in the name and phone numbers of the following:
School nurse _____________________________________________
Principal ________________________________________________
Superintendent ___________________________________________
Special Education _________________________________________
Section 504 Compliance Officer_______________________________
Teachers ___________________________________________
____________________________________________________
____________________________________________________
Physician(s): Names and Phone numbers
_______________________________________
_______________________________________
_______________________________________
______________________________________________________
Intake Form Part 2
CHILD'S CASE HISTORY:
For your child's advocacy file, please provide the following information.
1. Describe student's medical history and prognosis. What is student's current health status? Is your physician an ally and a strong advocate for your child?
2. Describe student's educational profile. What was student's level of performance, attendance and achievement before illness or injury? What are student's current educational and health management challenges?
3. What is the impact of student's condition on activities of daily living? school attendance? achievement? grades?
4. What is the impact of student's symptoms or condition on social relationships at school and in the community?
5. What is the impact of student's symptoms or condition on participation in extra curricular activities?
6. What is student's credit status?
7. What is the school climate? What are the attitudes of school officials or staff?
8. What policies and practices have been a help? a hindrance?
9. Is your child healthy at home but gets sick at school?
10. What is the current plan? Do you have an Individualized Education Plan, Individualized Health Plan or S. 504 Accommodation plan?
11. Has the school district given you the official booklet or document describing your child's rights under federal and state anti-discrimination laws and special education laws?
12. Who are your allies at school? in the community? Do you belong to a support group?
13. What other information do you think is significant or necessary for understanding your child's needs?
14. What would you like to see happen at school that is not happening now?
15. What would you like to stop happening at school?
16. Do you believe that your child is safe at school? If not, why not?
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