APPLICATION FOR EARLY CHILDHOOD HOME BASED INTERVENTION SERVICES
TODAY’S DATE: ______
NOTE: Please answer only those questions that are relevant to your family. The information you provide will be kept in strictest confidence by the Early Childhood Intervention Program.
CHILD’S NAME: ______
(First) (Middle) (Last)
SEX: Male Female DATE OF BIRTH: ______AGE: ______
(Day) (Month) (Year)
ADDRESS: ______
(House #, Street name, Box #, City/Town, Postal Code)
PARENT/FOSTER PARENT/ GUARDIAN: (Circle One)
NAME: ______NAME: ______
ADDRESS: ______ADDRESS: ______
CITY: ______POSTAL______CITY: ______POSTAL: ______
HOME PHONE: ______HOME PHONE: ______
CELL: ______WORK: ______CELL: ______WORK: ______
Relationship to child: ______Relationship to child: ______
SIBLINGS BIRTH DATE DOES CHILD LIVE WITH THIS SIBLING?
______YES NO SOMETIMES
______YES NO SOMETIMES
______ YES NO SOMETIMES
______ YES NO SOMETIMES
1a. Please describe your concerns about your child’s development.
______
______
______
______
______
b. Please describe why you would like to receive early childhood home based intervention services.
______
______
______
______
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c. In which of the following general skill areas would you like to see your child improve?
_____ feeding _____playing
_____ toileting _____ listening
_____ approaching people _____ understanding speech
_____paying attention _____ following directions
_____controlling temper _____ talking, communication
_____ walking or moving _____ getting along with others
_____using hands _____ dressing
_____ other, please specify______
______
Page 2 – Application for Parkland Early Childhood Intervention Program Service
AGENCY INVOLVEMENT:
Has your child been seen by, or is your child currently served by individuals at any of the following agencies or programs?
If Yes, how often / No / Date last seen or to be seen next1. Neonatal Intensive Care Unit (NICU)
Location:
2. Wascana Children’s Program ð
Kinsmen Children’s Program ð
Physician:
Occupational Therapist:
Physical Therapist:
Speech and Language Pathologist:
Social Worker:
Other:
3. Developmental Assessment Clinic
4. Community Health
Public Health Nurse:
Early Childhood Psychologist:
Sunrise Children’s Therapy Program
a. Physical Therapist:
b. Occupational Therapist:
c. Speech & Language Pathologist:
Family Physician:
Pediatrician:
Hearing Aid Plan:
5. Community Living Division
6. Child & Youth Mental Health Services
7. Social Services
8. Kids First:
9. School Division:
GSSD ð CTTSD ð Horizon ð Prairie Valley ð
10. Early Childhood Intervention Program:
11. Other (please list) ______
______
Page 3 – Application for Parkland Early Childhood Intervention Program Services
MEDICAL INFORMATION:
A. Please describe any significant events before, during and after the birth of your child:
______
B. Is your child receiving medications? If yes, please list and describe the effects on your child:
______
C. Has your child had a major illness and what are the effects?
______
D. Has your child been hospitalized? Why? At what age? What was the duration of his/her stay?
______
E. Please describe any hearing concerns:
______
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F. Please describe any visual concerns:
______
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G. Please describe any allergies:
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Page 4 – Application for Parkland Early Childhood Intervention Program Services
H. Does your child have any other physical and/or health needs that would affect program implementation for your child? Please describe.
______
I. Please describe your child’s strengths:
______
J. Any additional comments:
______
______
Signature of Parent/Legal Guardian Date
Page 5 – Application for Parkland Early Childhood Intervention Program Services Revised, July 2011