Abilities & Beyond Intake Form Question Title * 1. Parent/Guardian's Name (Last,First) Question Title * 2. Parent/Guardian's Phone Number Question Title * 3. Parent/Guardian's Email Question Title * 4. Child's Name (Last,First) Question Title * 5. Child's Date of Birth: Date Date Question Title * 6. Declared Disability (Select all that apply) ADHD Autism Spectrum Disorder Learning Disability Neuromuscular Disability Blind Deaf Visual Impairment Cerebral Palsy Down Syndrome Other (please specify) Question Title * 7. Verbal/Non-verbal Verbal Limited Non-Verbal Question Title * 8. Typical Behaviors (Select all that apply) Aggression Escaping ASB (Attention Seeking Behavior) Stimming Access Behaviors Lack of Voice Control (Screaming/Yelling) Other (please specify) Question Title * 9. Has Your Child Ever Done Sports Before? No Yes, please specify: Question Title * 10. Additional Comments/Concerns: Next
