Preliminary Registration – Welcome to Impact's TLC

Client Name *

Client Social Security Number (no dashes, no spaces) *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Gender? *

Male
Female

Diagnosis(es), i.e. Autism, Aspergers, ODD, Pica, etc.? *

Estimated Grade Level *

Previous Behavioral Discharge? *

Yes
No

Medication? *

Please respond n/a if not applicable.

Medication administered during business hours? *

Yes
No

Does client have allergies? If so, what is he/she allergic to? *

Please respond n/a if not applicable.

Does client have seizures? If so, date of last seizure? *

Please respond n/a if not applicable.

Client Support Services? *

Medicaid Waiver
AHCA
Private Pay

Please provide service authorization number:

Please upload Service Authorization letter.

Click or drag a file to this area to upload.

Does the client have transportation approval included in services?

Yes
No

Support Coordinator's Name (if applicable)

First

Last

Support Coordinator's Phone

Please upload Support Plan.

Click or drag a file to this area to upload.

Insurance Provider *

Please respond n/a if not applicable.

Policy Number

Parent/Guardian *

Parent/Guardian Email *

Alternate Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Alternate Phone

Emergency Contact *

Emergency Contact Phone *

Are you interested in before/after hours? *

Yes
No

Communication Skills? *

Highly Verbal
Semi-Verbal
Non-Verbal
American Sign Language

Feeding Skills *

Independent
Needs Assistance
Hand over Hand

Dietary Restrictions, if any?

Bathroom Skills? *

Independent
Needs Assistance
Untrained

Elopement Issues? *

Yes
No

Physical Aggression? *

Self-Injurious
Aggressive towards others
Disruptive Behaviors
N/A

Client interests, including favorite things? *

Does client enjoy social interaction with caregivers and peers? *

Job Skill Level *

Independent
With prompting
Hand over Hand

Previous Work Experience

Parent/Guardian goals for client? *