Client Intake Form

Please complete this form to help us understand your child, family, and support needs. A member of the Daveed Care Developmental Services Inc team will contact you to discuss next steps and possible services.

Fields marked with * are required.

Client Information (Child / Individual)

Full Name*

Preferred Name

Date of Birth*

Age

Gender / Pronouns

Primary Language*

Other Languages

Home Address*

City*

Postal Code*

Parent / Guardian / Primary Contact

Primary Contact Name*

Relationship to Client*

Phone (Primary)*

Phone (Secondary)

Email*

Secondary Contact (optional)

Emergency Contact

Name*

Relationship to Client*

Phone (Primary)*

Phone (Secondary)

Communication & Preferences

Preferred method of communication*

Phone Text message Email

Best days/times to reach you

Preferred language for communication

Accessibility or communication needs we should know about

Reason for Referral & Goals

Main reasons you are seeking support*

What has helped so far? (strategies, supports, routines)

Client strengths (what they are good at, positive qualities)

Activities the client enjoys

Type(s) of support you are interested in

Top 3 goals for support

Preferred days/times for services

Do you have funding for services? (e.g., SSAH, Passport, private)

Health & Safety (Basic)

Health conditions / diagnoses (if you wish to share)

Allergies (food, medication, environmental, other)

Specific safety concerns (e.g., running away, self-injury, aggression)

Consent to Contact

I consent to Daveed Care Developmental Services Inc contacting me regarding services and supports for the client named on this form.

Name (print)*

Date*