The intake packet is a "welcome kit" for new patients. It consists of all five of the forms below (each may be downloaded separately):
This is the cover letter to the intake packet that is normally mailed out to new patients prior to their appointment. Essentially, it is a welcome kit to the CCSN and it provides a description of the intake process, with details on what is needed for an appointment with the CCSN.
Description of Evaluations and Payment Options
This provides a description of each type of evaluation, including the purpose, and how each is conducted. Also included is information about the payment options for each type of evaluation.
Parent Questionnaire for Children younger than five
Parent Questionnaire for Children five years and above
The Parent Questionnaire is a comprehensive survey including: referral questions, current functioning within a variety of domains, medical history, developmental history, school history, social and family history.
Observer's Report Five and Under
Observer's Report Five and Above
Many children have multiple adults who can provide valuable perspectives when an evaluation is being conducted. The Observer's Report is a supplemental form that can be completed by caregivers -- other than the parent(s) who completed the Parent Intake Questionnaire -- such as a non-custodial parent, babysitter or relative.
An Observer's Report can also be completed by teachers, other than the primary teacher(s) who completed the School Intake Questionnaire, such as a reading teacher, classroom aide, school psychologist or speech-language pathologist. The Observer's Report can also be completed by private therapists or service providers.
The School Questionnaire is a comprehensive survey completed by the primary teacher or teaching team including: referral question, current functioning within a variety of domains, academic history and interventions provided. This form should be completed by the teacher or Early Intervention clinician who is most familiar with the child.
The Physician's Questionnaire allows the primary care provider an opportunity to communicate his or her observations, concerns and questions regarding the child being referred to the CCSN for evaluation. It also requests information regarding medical status and documents current hearing and vision testing.
Two-way release of information
This form authorizes the CCSN to release the patient's information to your physician or other care giver. (Please sign both page one and page two.)