Intake Form Parents/Legal Guardian Information Names:(Mother

Date__________
Long Island Early Childhood Direction Center
Intake Form
Parents/Legal Guardian Information
Names:(Mother)_____________________(Father)__________________________
Address:___________________________________________________________
City/State/Zip:______________________________________________________
What language(s) are spoken at home? English___Spanish____Other___________
Do you need an interpreter? Yes____No____
Phone: (home)_______________________Can we leave a message? Yes___No____
(cell)______________________ (work)____________________________
E-mail:__________________________
May we add you to our e-mail list? Yes
No
Child(ren) Information
1. Name:____________________________D.O.B________________________
Address (if different)____________________Gender:_____________________
School District:___________________________ Grade_________Age________
Diagnosis/Disability_______________________Year_____________________
2. Name:____________________________D.O.B________________________
Address (if different)____________________Gender:_____________________
School:___________________________ Grade_____________Age___________
Diagnosis/Disability_______________________Year_____________________
How may we help you? Please check the topic(s) that applies to you.
(1)___CPSE and CSE processes
9)____ Legal and Advocacy
(2)___Least Restrictive Environment
10)____Home School Collaboration
(3)___Parent’s Rights
11)____Transition ____a. Early Intervention
(4)___Day care and childcare services
____b. CPSE to CSE
(5)___Family Support and Respite Services
(6)___Social Services
(7)___Vocational and Job Training Programs
(8)___Evaluation and Diagnostic Services
(12)Other_____________________________________________________________
How did you hear about us?_____________________________________________
Question/Concern:
LIECDC staff member______________________________________
Action taken/Information provided/# of contacts: