KIDS NW | Client Intake Form | DSP Agency in Oregon

Name of Person completing this form*

Parent/Guardian Name*

First Last

Address*

Street Address City State ZIP

Phone Number*

Email*

County*

Name of Individual Receiving Services*

First Last

Age*

Date of Birth*

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ISP Goals*

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Describe Present Levels:

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Functional

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Behavioral

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Educational

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Social

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Emotional

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Service Coordinator / Case Manager:

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Does this individual share the same address as the Parent/Guardian?

Yes
No

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If not, what is the address of the individual?*

Street Address City State ZIP

Do you have a current ISP?*

Yes
No

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Does this individual have an intervention plan for dangerous behaviors?*

Yes
No

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If so, what is the intervention plan?

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Care History

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Emergency Contact Information

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First Contact Name

First Last

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Relationship to Individual

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Phone Number

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Second Contact Name

First Last

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Relationship to Individual

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Phone Number

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Third Contact Name

First Last

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Relationship to Individual

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Phone Number

Case Manager Contact Information

Case Manager Name

First Last

Case Manager Phone Number

Email

How many hours per month are allotted for Direct Support Professional Services?*

May we contact your Case Manager/ Service Coordinator?

Yes
No

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Case Manager Notes

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Hours/Days needed for services:

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Monday

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From:

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To:

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Tuesday

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From:

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To:

:

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Wednesday

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From:

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To:

:

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Thursday

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From:

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To:

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Friday

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From:

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To:

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Saturday

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From:

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To:

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Sunday

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From:

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To:

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Please indicate the types of services you desire.

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Other Service*

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How many hours per week do you desire a Direct Support Professional?

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Do you prefer a male or female Direct Support Professional?*

Male
Female
No Preference

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Do you prefer a Direct Support Professional who is a smoker or non-smoker?

Smoker
Non-Smoker
No Preference

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Is there anyone in your family/friend circle you would like K.I.D.S. set up to work as your Direct Support Professional?

Yes
No

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Name

First Last

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Phone Number

Comments:

By submitting this form I understand that I am authorizing the following: *KIDS, LLC to contact me about services. *For KIDS, LLC to share any pertinent information, history, and documentation with the Direct Support Professional that I have selected to provide services so that they are educated on the care that is needed. I understand that I may revoke this approval to share information by emailing Info@kidsnw.org.

Name
This field is for validation purposes and should be left unchanged.