Coaching Intake Form

Step 1 of 10 - Applicant Information

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Applicant Information

Name

First Last

Address

Street Address City State ZIP Code

Phone

Current Residence

Parent's Home

Dorm

Group Home

Independent Living

Other

If other, please specify

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Non-Binary

Both

Other

Neither

Pronouns Used

City of Applicant's Birth

City State / Province / Region Country

Insurance Information

Medi-Cal # or Insurance Carrier

Individual ID #

Group ID #

Phone

Address

Street Address City State ZIP Code

Primary Language

Languages Spoken in the Home

Regional Center Information

Is the applicant a regional center client?

Yes

Service Coordinator

First Last

Phone

Address

Street Address City State ZIP Code

Date of Most Recent IPP

MM slash DD slash YYYY

Please list current services being provided by the regional center:

Copy of Applicant’s Individual Program Plan

Max. file size: 100 MB.

Please answer the following questions.

1. What are my strengths at home, work and/or school?

2. What primary challenges am I currently facing?

3. What are some of the things that I am good at doing? At home, work or school?

4. 3 things I would like to do more often or learn how to do?

5. Any additional information about me that I think would be helpful?

Family Information

Is your Family Involved?

Yes

First Parent's Information

Parent's Name

First Last

Address

Street Address City State ZIP Code

Cell Phone

First Parent's Employment Information

First Parent's Name of Employer

First Parent's Job Title/Position

First Parent's Work Address

Street Address City State ZIP Code

First Parent's Work Phone

First Parent's Ext.

Add Another Parent?

Yes

Second Parent's Employment Information

Second Parent's Name

First Last

Second Parent's Name of Employer

Second Parent's Job Title/Position

Second Parent's Work Address

Street Address City State ZIP Code

Second Parent's Work Phone

Second Parent's Ext.

Significant Family Members/Siblings?

Yes

Significant Family Members/Siblings

Name

First Last

Relationship

Age

Name

First Last

Relationship

Age

Other Household Information?

Yes

Other Household Information

Name

First Last

Relationship

Age

Name

First Last

Relationship

Age

Name

First Last

Relationship

Age

Emergency Contact Other Than Parent?

Yes

Emergency Contact Other Than Parent

Name

First Last

Relationship

Age

Medical History

Name of Primary Care Physician

Address

Street Address City State ZIP Code

Date of Most Recent Physical

MM slash DD slash YYYY

Do you have any chronic or serious health conditions?

Yes

If yes, please describe:

Do you have any health restrictions or limitations?

Yes

If yes, please describe:

Do you have any allergies?

Yes

If yes, please describe:

Have you been hospitalized in the past three years?

Yes

If yes, please describe:

Are you currently taking any medication(s)

Yes

If yes, please describe:

History of Interventions

A. Diagnosis

Have you been diagnosed with a developmental or learning disability?

Yes

If yes, please specify the diagnosis and the date of diagnosis

MM slash DD slash YYYY

Who diagnosed you?

First Last

Agency

Phone

B. Please indicate if you have received or are currently receiving services in the following areas

Speech and Language

Yes

Name of Service Provider

Phone

When were you last assessed for these services?

MM slash DD slash YYYY

What are the goals of this intervention?

Psychotherapy

Yes

Name of Service Provider

Phone

When were you last assessed for these services?

MM slash DD slash YYYY

What are the goals of this intervention?

Occupational Therapy

Yes

Name of Service Provider

Phone

When were you last assessed for these services?

MM slash DD slash YYYY

What are the goals of this intervention?

Educational Therapy or Tutoring

Yes

Name of Service Provider

Phone

When were you last assessed for these services?

MM slash DD slash YYYY

What are the goals of this intervention?

EDUCATIONAL/VOCATIONAL HISTORY

Do you currently attend or participate in?

College

Work Training Program

Competitive Employment

None

High School

Other

If other, please specify

Name Of Current School, Program, or Employer

Date Started

MM slash DD slash YYYY

Address

Street Address City State ZIP Code

Phone

Contact Person

Are you working?

Yes

If you are working, what position do you hold and how many hours do you work?

Work Address

Street Address City State ZIP Code

Work Phone

Work Contact Person

Please check primary issues that impact your ability to progress in academic, vocational, and/or community-based endeavors:

Transitioning from home to school and/or work settings

Difficulty with organization

Self-advocacy with employers, instructors and/or peers

Balancing study/work & recreational time

Developing appropriate personal, school & work relationships

Money management (budgeting, paying bills, balancing check book

Developing/maintaining motivation to pursue goals & interests

Difficulty with taking medication independently

Challenges with developing and maintaining consistent hygiene

Other

If other, please specify:

REFERRAL SOURCE

Please provide the following information regarding the person or organization that referred you to Advance LA.:

Name

First Last

Agency

Address

Street Address City State ZIP Code

Contact Person

First Last

Phone

Other, please specify:

AUTHORIZATION AND AGREEMENT

Signature

I authorize investigation of all statements contained in this Application for Enrollment in Advance LA. In the event of admission, I understand that false or misleading information, given in the application, or in any interviews, may result in rescission of any admission. I understand also that continued participation in Advance LA services requires the applicant to abide by all rules and regulations of the program.

Date of Application

MM slash DD slash YYYY

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