Client Information

Client's Full Name*

Birthday*

Martial Status*

Race/Ethnicity (Optional, select all that apply)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Other

Gender Identity and Preferred Pronouns*

Primary Language*

Does the individual require interpreter services?*

Does the individual require transportation services?*

Diagnostic Information

What is the individual’s current diagnosis?*

Who was the diagnosing physician?

Briefly describe areas of strength for the individual as well as some enjoyable items, tasks, or activities*

Briefly describe areas of difficulty the individual is experiencing*

Is the individual...(Check all that apply)*

Sensitive to bright lights

Sensitive to loud sounds

Sensitive to crowded spaces

Sensitive to certain textures

None of these

Only applicable to clients under 18 years old

School District

Current Grade

Does the individual have a current IEP or AEP?

IEP

AEP

None

4134 Linden Ave, Dayton OH 45432

By Appointment Only

Call or Text: 937-365-7455

Fax: 937-600-6071

Monday - Friday: 9:00am – 6:00pm

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