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FC - Intake Form For Child

This document contains a child intake form with several parts. Part A collects basic information about the child and family, including the child's name, birthdate, address, and parents' names and contact details. Part B gathers the child's medical information from specialists. Part C presents the results of an ECCD checklist assessment of the child's development across several domains. Part D consists of interview notes with the parents regarding the child's interests, behavior, daily routine, and other considerations. The form is used to obtain a holistic understanding of a child's needs and situation to help manage delays and disabilities.

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Glenda Ang Bacomo
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40 views2 pages

FC - Intake Form For Child

This document contains a child intake form with several parts. Part A collects basic information about the child and family, including the child's name, birthdate, address, and parents' names and contact details. Part B gathers the child's medical information from specialists. Part C presents the results of an ECCD checklist assessment of the child's development across several domains. Part D consists of interview notes with the parents regarding the child's interests, behavior, daily routine, and other considerations. The form is used to obtain a holistic understanding of a child's needs and situation to help manage delays and disabilities.

Uploaded by

Glenda Ang Bacomo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Guidebook in Managing Children with Delays and Disabilities / ECCD Council

CHILD INTAKE FORM

Part A. Basic information about the child and family


A.1. Information about the child
Name: Sex:
Birthdate: Age:
Address:
A.2. Information about the parents
Father’s Name: Mother’s Name:
Age: Age:
Occupation: Occupation:
Contact number: Contact number:
A.3. Information about other members of the family/household
Name: Age: Sex: Relation to child

Part B. Medical Information of the child


Name of Specialist:
Designation:
Medical Findings:
Medical notes and recommendations:

General considerations:

Accomplished by: Date:


______________________________ ____________________
(Signature over printed name) (Month/Day/Year)
Guidebook in Managing Children with Delays and Disabilities / ECCD Council

Part C. Latest results of assessment using the ECCD Checklist


Date of assessment: Age of the child during assessment:

Domain Raw Score Scaled Score Interpretation


Gross Motor 13 13 Average overall development in the domain
Fine Motor 10 13 Average overall development in the domain
Self-Help 23 10 Average overall development in the domain
Receptive Language 5 11 Average overall development in the domain
Expressive Language 8 11 Average overall development in the domain
Cognitive 20 15 Suggests sllighty advanced development in the
domain
Socio-Emotional 22 11 Average overall development in the domain
Sum of Scaled Scores 83
Standard Score 116 Average overall development in the domain

Part D. Interview notes with the parents and/or other members of the family/household
Child’s interests: What are the things/activities does your child like or hate? Where do you think your child is
very good at doing?

Child’s behavior: How does your child behave when playing, interactin and doin family activities at home? How
does your child behave when in other places?

Child’s routine: What are the usual activities your child do with your family in a day? What does your child do
from morning until night?

Other considerations: Are there other things that you like to share about your child?

Accomplished by: Date:


______________________________ ____________________
(Signature over printed name) (Month/Day/Year)

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