Appendix 1

Get Set Learn Parent Intake Form 2008

File # Date
Name:

Address:

Telephone Number:
Cell Phone: 		Date of Birth (year only):
Marital Status: Transportation:
Child's Name:

 Gender Age
     
     

 

How did you hear about GSL? flyer at site
cheque insert Caseworker friend Other

Allergies:
Caseworker Name:


Education and Training
pease check all that apply Specify
Grade School    
High School    
Trade School    
Upgrading/ESL    
College/University    
Other    

 

Language Spoken Languages Written
English  
French  
Other (specify)  

 

Goals:
What do you hope to get out of this program for yourself – (goal)?

  
What skills would you like us to help your child with?
  1. School ready
  2. Socialization
  3. Learn Numbers/letters
  4. Better English speaking skills
  5. Other
what essential skills do you need help with?
  1. Thinking Skills
  2. Oral Communicaton
  3. Working with Others