Preschool Intake Form printable pdf download

2016

Preschool Intake Form

Date: ___________________________

Start

Birth Date: ___________________________

Child’s Name: ______________________________________________________________________________

First

Middle

Last

Does your child have a nickname he/she would prefer to use? _________________________________________________________

Sibling’s names and ages: ______________________________________________________________________________________

___________________________________________________________________________________________________________

Please list other members of the household: _______________________________________________________________________

___________________________________________________________________________________________________________

Are there other adults that care for your child? _____________________________________________________________________

___________________________________________________________________________________________________________

Please help us get to know your child by completing the following information. All information is kept confidential

and shared only with the classroom teachers.

Health History: Does your child have:

Any known allergies (food, environmental, medication)? _____________________________________________________________

___________________________________________________________________________________________________________

Any medications taken regularly? ________________________________________________________________________________

____________________________________________________________________________________________________________

Have any physical disabilities? ___________________________________________________________________________________

____________________________________________________________________________________________________________

Have there been any serious illnesses or hospitalizations? ____________________________________________________________

___________________________________________________________________________________________________________

Receive assistance from Child Find or received assistance in the past from Birth to Three? __________________________________

___________________________________________________________________________________________________________

If so, does your child have an IEP? _______________________________________________________________________________

Please note if your child does have an IEP, that information must be shared with the classroom teacher so that we can work together

to help your child succeed.

Family:

What language(s) are spoken at home? ___________________________________________________________________________

What language(s) does your child speak? __________________________________________________________________________

What holidays are celebrated in the home? ________________________________________________________________________

____________________________________________________________________________________________________________

What are some of your child’s favorite activities? ___________________________________________________________________

____________________________________________________________________________________________________________

How does your child handle anger and frustration? __________________________________________________________________

What steps do you take when your child is angry/frustrated/not listening? _______________________________________________

Does your child wander away or hide while in public places? ___________________________________________________________

Does your child indicate when he/she needs to use the bathroom? _____________________________________________________

Does your child have frequent toilet accidents? _____________________________________________________________________

Does your child wipe himself/herself after a bowel movement? ________________________________________________________

Does your child need assistance with clothing when using the bathroom? ________________________________________________

Is your child able to dress self (put on and remove basic clothing and outerwear)? _________________________________________

Does your child nap? (Please circle)

Daily

2-3x week

Rarely

What is your child’s night sleep schedule? _________________________________________________________________________

____________________________________________________________________________________________________________

Preschool Intake Form

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