Get Children With Special Needs Program

Filling out the Children With Special Needs Program intake form online is an essential step in ensuring that your child receives the best possible care. This guide provides clear and supportive instructions for completing each section of the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date in the designated space at the top of the form. Next, fill in your child's name and date of birth, followed by the name of their parent or guardian.
3. Provide your current address, phone number, cell phone, and work number. Ensure that you include an email address, as this will be used for important updates regarding your child's information and events.
4. Fill in the emergency contact information, ensuring you include their name and phone number for reachability in case of an emergency.
5. Indicate whether your child has special needs by selecting the appropriate option. If your child has siblings, list their names and ages in the provided space.
6. Complete the section regarding the pediatrician's details by providing their name, address, and phone number.
7. Document your child's diagnosis along with the age at which the diagnosis was made.
8. In the patient-physician relationship section, circle the appropriate response indicating how cooperative your child is during medical visits.
9. Answer the questions regarding your child's behavior during medical procedures, including whether they can be separated from other patients and if they can tolerate injections or physical examinations.
10. Respond to the compliance and behavior problems section by circling the appropriate responses to questions related to aggression and strategies you have found helpful.
11. Assess your child's level of independent functioning by circling a number from 1 (totally dependent) to 5 (totally independent).
12. Indicate if your child has any significant hearing or visual problems, as well as any recent illnesses or emotional disturbances that might affect behavior.
13. Complete the language section by indicating whether your child is verbal, nonverbal, or can communicate reliably in other ways.
14. Finally, provide any additional information that might be useful for the physician in treating your child, using the space provided at the end of the form.
15. Once you have filled out all the sections of the form, review your entries for accuracy. Save your changes, download, print, or share the form as necessary.

Take the first step in enhancing your child's care by completing the intake form online today.