Inclusion Intake Form — Nonsensical Society for Kids

Additional Support Intake Form

Next Steps!

Please note that completing this form does not guarantee a spot for your child, we will reach out to set up a meeting once we receive your completed intake form.

For any questions before you start the process email us at nonsensicalsocietyforkids@gmail.com

Name

First Name

Last Name

Pronouns

Birthday

YYYY

School (if applicable)

Choice of Program

Diagnosis/es

Likes:

Dislikes:

Goals:

Allergies/Food Sensitivities

Sensory Needs:

Ex: requires noise cancelling headphones, wear chewelry necklace, etc.

Mobility Needs

Ex: uses walker, wears AFO’s, etc.

Anything else we should know!

Emergency Contact #1 Name

First Name

Last Name

Phone

(###)

###

####

Emergency Contact #2 Name

First Name

Last Name

Phone

(###)

###

####

Additional Support Intake Form

Next Steps!

Questions? We’re here to help.