Client Intake Form — Compass Care Colorado

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Family & Contact Information

Let's start with the basics so we know who we're working with and how to reach you.

Parent / Guardian Name *

Relationship to Child *

Best Phone Number *

Email Address *

Home Address * We use this to confirm we serve your area and to plan any travel

Is there a second parent / guardian?

Second Guardian Phone

Preferred Contact Method

About Your Child

Child's First Name *

Date of Birth *

Pronouns

School / Program (if applicable)

Services You're Interested In *

In-Home Babysitting Respite Care ABA-Informed Support School Pickup & Aftercare Parent Consultation Not Sure Yet

How did you hear about Compass Care Colorado?

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Diagnosis & Medical History

This helps us understand your child's clinical background and ensure we're fully prepared for their care. All information is confidential.

Why we ask: Knowing your child's diagnoses and medical needs isn't about labels — it's about making sure we have the right knowledge, strategies, and preparations in place before we ever walk through your door.

Primary Diagnosis / Diagnoses * List all that apply, e.g. Autism Spectrum Disorder (Level 2), ADHD, Down Syndrome

Age at Diagnosis

Currently Receiving ABA Therapy?

Other Therapies Currently Receiving

Speech Therapy (SLP) Occupational Therapy (OT) Physical Therapy (PT) Feeding Therapy Mental Health Counseling Social Skills Group None currently Other

Known Allergies * Food, environmental, medication, bee stings — anything we need to know

Current Medications * Name, dosage, and timing. Note if any need to be administered during care.

Does Your Child Have a History of Seizures?

Seizure / Emergency Action Plan Details If yes above, describe what to do and any triggers we should know

Any Other Medical Conditions or Physical Needs? E.g. feeding tube, mobility devices, vision/hearing impairments, cardiac conditions

Child's Physician / Pediatrician

Physician Phone Number

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Section 3 of 7

Communication Style & Language

Understanding how your child communicates — and how they prefer to be communicated with — is one of the most important things we can learn.

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Sensory Needs & Triggers

Sensory information helps us create a safe, comfortable environment and avoid situations that may cause distress.

Tip: Feel free to check multiple boxes and use the open text fields to add detail. There are no wrong answers — the more specific you are, the better prepared we'll be.

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Daily Routine & Schedule

Consistency and predictability are key for many autistic and special needs children. Help us understand their day so we can maintain what matters most.

Typical Wake Time

Typical Bedtime / Sleep Routine Start

Morning Routine Walk us through what mornings typically look like — in order

Afternoon / After School Routine

Evening / Bedtime Routine

Food & Eating

Meal Times & Food Preferences Include preferred foods, refused foods, textures, and any feeding concerns

Are There Any Foods That Are Off-Limits or Could Cause a Serious Reaction?

Activities & Interests

Favorite Activities & Strong Interests * These are gold — we'll use them to build connection and motivation

Activities Your Child Dislikes or Refuses

Screen Time — Is It Allowed During Care?

Screen Time Details / Limits

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Behavioral Strategies & Interventions

As an RBT, I work within your child's existing behavior support framework. This section helps me stay consistent with what's already working for your family.

Important: I will never introduce new behavior strategies without discussing them with you first. My goal is to support and reinforce what your child's care team has already established.

Does Your Child Have an Active Behavior Support Plan (BSP) or Behavior Intervention Plan (BIP)?

Key Behavior Strategies Currently in Use E.g. First-Then, token boards, choice boards, extinction, planned ignoring, etc.

What Reinforcers Work Best for Your Child? What motivates them? What do they work hardest for?

Challenging Behaviors We Should Be Aware Of Please describe any behaviors that occur, their typical triggers, and how you currently respond

Safety Concerns We Must Know About Elopement, self-injurious behavior, aggression toward others, pica, etc.

Elopement (running away) Self-injurious behavior (hitting self, head-banging) (hitting self, head-banging) Aggression toward others Pica (eating non-food items) Climbing in unsafe ways Water safety concerns No current safety concerns

Safety Details & Protocols For any safety concerns above, please describe what we should do

What Should We NEVER Do With Your Child? Approaches, phrases, consequences, or situations that make things worse

Anything Else About Your Child's Behavior We Should Know?

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Emergency Contacts & Parent Preferences

Almost there! Let's make sure we have everything needed for safety and so we can meet your family's specific expectations.

⚠️ Please complete this section carefully. Emergency contact and medical authorization information is critical and will be kept on file for every care session.

Emergency Contacts

Emergency Contact #1 Name *

Relationship to Child *

Phone Number *

Can Authorize Medical Treatment?

Emergency Contact #2 Name

Relationship to Child

Phone Number

Can Authorize Medical Treatment?

Nearest Hospital & Medical Authorization

Preferred / Nearest Hospital *

Insurance Provider

Medical Authorization Statement * By checking the box below, you authorize Compass Care Colorado to seek emergency medical treatment for your child if you cannot be reached in an emergency. I authorize Compass Care Colorado to seek emergency medical care for my child if I cannot be reached.

Parent Preferences & Expectations

How Would You Like to Be Updated During Care Sessions?

Text message updates Photo / video updates Written session notes only Only contact me if there's an issue Check-in at start and end No preference

Are There Any Household Rules or Caregiver Expectations We Should Know?

Are There Any Family Members, Topics, or Situations That Should NOT Be Discussed With Your Child?

What Would Make This the Best Possible Care Experience for Your Family? Your vision matters — tell us what success looks like

Anything Else You'd Like Us to Know?

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge, and I consent to it being used by Compass Care Colorado to provide care for my child. I confirm all information above is accurate and I consent to its use by Compass Care Colorado.

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