Intake Form And Questionnaire

Due to our non-profit status, we must keep the following information on file. Please be assured that your answers to these questions will in no way influence your child’s possible admission. Tomorrow’s Voices does not discriminate based on age, gender, race, or national origin.

Instructions: Please complete this document in its entirety (including copies of related information where requested) to best assist us with your child’s assessment. Once you have completed the document we will schedule our therapist to have a brief interaction with your child.

Areas:

Client Information
- PLEASE INCLUDE COPIES OF DIAGNOSTIC ASSESSMENT
Parent/Legal Guardian Information

"*" indicates required fields

Client Information

Program of Interest*

Early Intervention Services

Adult Services

Name*

First Middle Last

Date of Birth*

Age*

Sex*

Male

Female

Home Phone

Requested Start Date (if any)

Mailing Address (if different than home)

Custodial Parent/Guardian

Client lives at (select one)*

Home

Residential Facility

Other

Contact Person at Group Home & Phone Number

Client’s Primary Diagnosis

Date of Diagnosis

Age

Facility that Made the Primary Diagnosis

Secondary Diagnosis

Date of Diagnosis

Age

Facility that Made the Secondary Diagnosis

Other Diagnosis

Date of Diagnosis

Age

Facility that Made the Other Diagnosis

PARENT/LEGAL GUARDIAN INFORMATION

Parent #1

Mother’s Name*

Title

Mailing Address (if different than home)

Cell Phone*

Email*

Parent #2

Father’s Name*

Title

Home Address

Mailing Address (if different than home)

Home Phone*

Cell Phone*

Email*

Guardian #1

Name*

Title

Home Address

Mailing Address (if different than home)

Home Phone

Cell Phone

PLEASE NOTE: In order for the client’s experience at Tomorrow’s Voices to be a success, we ask each family to attend team conferences, in-centre observations and parent/guardian workshops so that effective follow-through may occur at home. This is mandatory for the client’s enrollment within the Tomorrow’s Voices program.

The client who will benefit most from enrollment at Tomorrow’s Voices is a client whose parent(s)/guardian(s) are supportive of the principles and practices of applied behavior analysis (ABA), specifically B. F. Skinner’s analysis of verbal behavior. Tomorrow’s Voices will be incorporating a variety of methods and therapies into the client’s program, but the core program will be based on the principles and practices of Skinner’s analysis of verbal behavior.

Parent(s)/Guardian(s) must contribute at least 3 volunteer hours per month at Tomorrow’s Voices or in assisting Tomorrow’s Voices with any fundraising efforts, this volunteer assistance will help Tomorrow’s Voices in keeping our costs down.

Parent/Guardian 1

Parent/Guardian 2

Signature 1*

Signature 2

Upload Assessment Document

Drop files here or

Max. file size: 8 MB.

Please submit completed application and questionnaire using the Next Step button below. If successful in being admitted, the application fee will be applied to the client’s program fees.

Intake Form And Questionnaire

Client Information

PARENT/LEGAL GUARDIAN INFORMATION

Contact Information

Useful Information