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

Child Information
Today's Date
Date of Intake
Which location are you interested in:
Child's Name
Date of Birth
Current Age
Primary Language
Home Address
Child’s Diagnosis (if any) and Insurance Code
Please provide any reports (doctor’s, EI, school) that may be helpful as additional information at the intake process.
Reason for Referral
Who referred you to the FUSE Program

Parent/Guardian Information
Parent/Guardian Name(s)
Relationship to Child
Home Address
Home Phone
Cell Phone
Email
Does your child have any siblings?
Names
Ages

Developmental History and Background Information
Age began sitting
Crawling
Walking
Talking
Any speech difficulties? Does or has your child receive speech therapy services?
Please list examples of how your child communicates. (words, gestures)

Health
Any known complication at birth?
Serious illnesses and/or hospitalizations
Special physical conditions, disabilities
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions
Regular medications

Eating Habits
Child eats with hands (yes or no)
- Yes
- No
Spoon (yes or no)
- Yes
- No
Fork (yes or no)
- Yes
- No
Special characteristics or difficulties
Favorite foods: (not all are allowed)
Foods refused

Toilet Habits
Does your child use the toilet independently?
- Yes
- No
How does child indicate bathroom needs (include special words)?
Is child ever reluctant to use the bathroom?
Does child have accidents?
Does child become tired or nap during the day (include when and how long)?
When does child go to bed at night?
When does your child get up in the morning?
Describe any special characteristics or needs (stuffed animal, story, mood on waking, etc.)

Social Relationships
How would you describe your child’s temperament?
How does your child respond to new people?
Describe your child’s interest in playing with other children
How does your child interact with other children?
How does your child respond when something unexpected happens?
How does your child respond when an activity is introduced that is less preferred?
What does your child like to play with? Favorite toys and activities
Fears (the dark, animals, etc.):
How do you comfort your child?
What is the method of behavior management/discipline at home?
Does you child use his/her words? Please describe:
Does your child use his/her words? Please describe:
How does your child make his/her needs know? Please describe:
Does your child attend preschool, school, daycare? If so, where?
Does your child participate in any additional services? OT, SLP, Other:
Describe your child’s schedule on a typical day?
What are two short term and long-term goals you think FUSE will be able to work on for your child?
Is there anything else you would like us to know about your child?
Parent/Guardian Signature:
Date:

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.

Intake Evaluation Form

Step 1 of 7

Child Information

Parent/Guardian Information

Developmental History and Background Information

Health

Eating Habits

Toilet Habits

Social Relationships