Majestic Minds Intake Form

Please fill out this intake form. Fill the information click submit at the end of the form. Alternatively you can send the filled form to us via e-mail  to [email protected]

Client's Name *

First

Last

Please enter child's first and last name

Primary Email *

Email

Confirm Email

Primary Phone Number *

Child's Date of Birth

Primary Diagnosis

Emergency Contact

Please list all other treatments currently on going or treatments taken in the past

Allergies

Requested start date

Emergency Contact Phone Number

Primary Contact Name

First

Last

Other Phone Number

Secondary Contact Person

First

Last

Secondary Email

Email

Confirm Email

Secondary Phone Number

Secondary Other Phone Number

Child's Primary Mailing Address

Name of primary individual approved to pick up client from program

Relationship of primary individual approved to pick up client from program

Phone Number of primary individual approved to pick up client from program

Languages Spoken at Home

Number of Siblings

Number of siblings child has

Child's Primary Physician

Child's Medical Specialist

Current Medication(s) Child is taking

Does the child experience seizures?

• Yes
• No

Does the child require specialized diet or medication

• Specialized Diet
• Specialized Medication
• Specialized Diet & Medication

Requested to administer medication

• Yes
• No

Specify medication

If yes to administer medication

Describe the child's strengths

Describe child's current school performances: (levels of attention/focus, special arrangements etc):

Describe the child's area of difficulties

Describe child's current social performance

Child's short term goal:

Describes child's behaviour

Child's interests

Child's long term goal:

Additional information about the child

Submit