Intake Case History & Family Needs Profile

At REACH Behavior and Development Center we are committed to safeguarding the privacy and confidentiality of the information provided by our clients. As a BHCOE (Behavioral Health Center of Excellence) facility, we adhere to stringent standards to ensure the protection of sensitive data.
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How did you hear about us?المدينة
DD slash MM slash YYYY

Preferred Mode of Contactالمدينة

Number of siblings, names, and ages:

Please indicate which of the following services your child is currently receiving or has received in the past:
(Examples: Asthma, Diabetes, Heart condition, Neurological condition)
Mode of Communicationالمدينة
(For example: Pencil grip, Scissor skills, Writing name/writing legibly)
(For example: Ball kicking, Catching, Throwing, Aiming at a given target?)
(For example: Flapping hands, Accepting and/or avoiding different textures, Covers ears in loud environments)
(For example: eating, toileting, dressing, washing/bathing)
Does your child have any of the following?

Please indicate what service/s you are seeking:المدينة
This field is for validation purposes and should be left unchanged.

All information collected through this form is treated as confidential and will only be used for the purposes stated within the context of our services. We do not disclose any personal information to third parties without explicit consent unless required by law.

Please be assured that your data is securely stored and accessible only to authorized personnel who are bound by confidentiality agreements. We take the responsibility of protecting your privacy seriously and maintain strict protocols to prevent unauthorized access or disclosure.

By submitting this form, you acknowledge and consent to the collection and use of your information by our privacy practices. If you have any concerns or questions regarding the confidentiality of your data, please do not hesitate to contact us.

Thank you for entrusting us with your information and we look forward to meeting you.