Daycare Behavior Support – Client Information & Consent Form

Welcome!

Thank you for taking a few minutes to complete this intake form. Once you submit it, we will reach out within 1–2 business days.

Child Information

First name*

Last name*

Birthday*

Month

Day

Year

Grade/Classroom*

Daycare Name *

Has your child received any diagnoses?*

Yes

In the process of evaluation

If yes, please list any diagnoses (check all that apply or write in):

ADHD

Autism Spectrum Disorder (ASD)

Speech or Language Delay

Developmental Delay

Sensory Processing Differences

Other

Is your child currently receiving any services? (Check all that apply):

Speech Therapy

Occupational Therapy

ABA/Behavior Therapy

Early Intervention

School-based services (IEP/504)

None at this time

Parent/Guardian Information

Name*

Phone*

Email*

Reason for Support/Concerns

Briefly describe the behaviors or skills you want support with:*

Session Preferences

Preferred Session Length:*

1 Hour ($100)

2 Hours ($200)

Preferred Frequency *

Once per week

Twice per week

Preferred Days & Times *

Optional Behavior Support Plan

Would you like a custom behavior support plan with strategies for home and daycare?*

Yes ($125)

Consent & Agreement

I, the undersigned, understand and agree to the following:

This service is paid directly by the parent; the daycare is not responsible for costs.
Services include observation, brief staff guidance (with consent), and parent debrief with strategies.
Sessions are short-term, skill-building support, not full-day 1:1 care.
I consent to the Consultant being present in the classroom and working with staff to support my child.
All notes, observations, and behavior plans will remain confidential and shared only with me unless otherwise authorized.

Signature*

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