Patient Intake Form - Special Accommodations
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1Patient Intake Form – Special Accommodations
Patient Demographics
Patient Name:_________________________
DOB: ___________________
Diagnosis: _________________
Parent/Guardian: ________________________________________________
Phone #: __________________
Communication
My child:
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Speaks in full sentences
Speaks in short phrases
Speaks 1-2 word responses
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Non-verbal
Uses a communication device: __________________________
My child communicates best using:
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Spoken language
Pictures
Written words
Behavioral
My child’s specific interests or favorite objects include:
1)_____________________________________________________________________________
2)_____________________________________________________________________________
3)_____________________________________________________________________________
My child’s dislikes or things that upset my child include:
1)_____________________________________________________________________________
2)_____________________________________________________________________________
3)_____________________________________________________________________________
Suggestions for my child
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Use simple, direct language
Allow time for processing questions or instructions
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Provide 2-3 choices when offering items/ activities
Give ‘2 minute’ warning before changes/transitions
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Keep lights dimmed
Keep noise levels low
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Model any necessary procedures
Create a visual schedule of necessary procedures
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Create a written schedule of necessary procedures
Earn a reinforcer at the end of the visit __________
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Other: ___________________________________
Other: ___________________________________
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Parent category: Business