EARLY EARLY INTERVENTION INTERVENTION INTAKE INTAKE FORM FORM by JaymesChapman

VIEWS: 83 PAGES: 2

									                                                   Guam Public School System, Division of Special Education
                                                                   Guam Early Intervention System
                                                                 P. O. Box DE Hagatna, Guam 96932
                                       Phone: 671-565-2961 ext. 5776 or 5816 Email: geis@teleguam.net or www.guameis.com


                                                        EARLY INTERVENTION INTAKE FORM

 Child’s Name: _______________________                _____________________________ ___________                       Date of Birth: ___________________
                Last                                    First                        Middle (I)
 Gender: ______________          Ethnic Identity: _________________________________ Primary Language: ____________________________________

 Health Insurance: _______________________________               Primary Physician: _______________________________________________________________

 Home Address:      ___________________________________________________________________________________________________________________

 Mailing Address: ___________________________________________________________________________________________________________________

 Mother’s Name: ________________________________________________ Father’s Name: _____________________________________________________

  Home Phone: ______________________ M Wk Ph: ______________________________                     F Wk Ph: ___________________________________________

   M Wk Site: _______________________________________________                F Wk Site: ____________________________________________________________

   M Email Address: __________________________________________________ F Email Address: ___________________________________________________



 Major Concerns/Health Issues:___________________________________________________________________________________________________________

 _______________________________________________________________________________________________________________________________________

 _______________________________________________________________________________________________________________________________________

 _______________________________________________________________________________________________________________________________________

 Medical Diagnosis: ______________________________________________________________________________________________________________________

 History of Ear Infections? N      Y     How many? ____________              Frequency: ____________     Immunization current? _________________________

 Was the child born    Ο Full Term          Ο Premature      How many weeks? ______________________________________________________




                                                    [ To be c omp let ed b y Ref er rin g Ag en cy / P e rson ]

Person making referral: _______________________________________________________________________________________________________________

Agency or relationship to child: _____________________           How did you hear about this program: ________________________________________________

Office Phone: __________________ Office Fax: __________________ E-Mail: _________________________________________________________________


                                                   [ Re lease Of In forma tion Consen t: Op tional                ]

I, ________________________________ (Print name of parent or guardian), give my permission for, __________________________________

(print provider’s name), to share any and all pertinent information regarding my child, _________________________________ (print child’s

name), with the early intervention program.

Parent/Guardian Signature: _____________________________________________________________ Date: ____________________________


                                      [ To be c omp let ed b y Gua m Ea rl y Inte rv entio n /Sp e cial E duc ation ]
Intake Received by : ___________________________________________________       Date received by GPSS :_______________________________________


                                                   [ To be c omp let ed b y GEIS Pr og ra m Ad ministr ato r ]

Is this child currently receiving early intervention services?      Y    N   If yes, current SC ___________________________

SC Assigned : _______________________________               Date assigned: ____________      Transdisciplinary Team: ___________________________________
(revised 3/5/2009)

								
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