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Intake Evaluation Form

Your payment is due at the intake session. An intake session costs $200.00.  If paying by check, please make it payable to FUSE Program LLC. After your intake, you will receive a paid invoice that you may be able to submit to insurance for reimbursement.
Typically, PPO insurance plans will reimburse services.
Please read additional info below form. 

This information needs to be kept on file while children are in care.

Step 1 of 7

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  • Child Information

  • Please provide any reports (doctor’s, EI, school) that may be helpful as additional information at the intake process.

Intake Evaluations last about an hour.

You can bring a snack (nut free) and a water bottle for your child to have if she/he needs a break.

The first half of the appointment will be play based. We will assess and evaluate aspects related to the foundation of social problem solving and collaboration – such as social referencing, co-regulation, social flexibility, communication for collaboration and perspective taking.

The second half of the session will be a discussion with parents about observations of the child, strengths and weaknesses, related to the above areas. We will then discuss programming options and programming goals.

At the end of the Intake we will create a plan for your child of FUSE services that are appropriate.

Please bring something for your child to do during the parent conversation portion – books, IPAD, activity book etc.