Progressive Point Learning – Full Intake Form

This intake form includes application information, consent, liability, confidentiality, and support planning details.

1. Client Application Overview

Child Name

Date of Birth

Age

Parent/Guardian Name

Phone

Email Address

School / Program

Grade/Class

2. Consent & Service Disclaimer

Scope of Services

Progressive Point Learning provides educational, behavioral, and emotional support services for children with ADHD, Autism Spectrum differences, and learning challenges. Services may include classroom shadowing, behavioral regulation support, task initiation and completion, executive functioning strategies, and collaboration with parents and educators.

No Formal Diagnosis

Progressive Point Learning does not provide medical, psychological, or educational diagnoses. All services are supportive in nature and do not replace evaluations or treatment by licensed professionals.

[acceptance* consent-services] I give permission for my child to receive services in home, school, and community settings as appropriate.

3. Liability Release

I understand that Progressive Point Learning staff provide supportive services and supervision but are not responsible for pre-existing conditions, injuries, or incidents beyond reasonable control. I release and hold harmless Progressive Point Learning, its staff, and affiliates from liability arising from participation in services, except in cases of gross negligence.

Parent/Guardian Signature (type full name)

Date

[acceptance* liability-agree] I have read and agree to the liability release above.

4. Confidentiality & Privacy

Progressive Point Learning respects the privacy and confidentiality of all families served. Information collected is used solely for service planning and support. Information will not be shared without written consent, except as required by law or for child safety concerns.

[acceptance* confidentiality-agree] I have read and understand the confidentiality and privacy statement above.

5. Classroom Shadowing – Data Collection Sheet

Student Name

Observation Date

School / Classroom

Observer

Task Initiation

Task Completion

Behavior Regulation

Attention / Focus

Peer Interaction

Teacher Interaction

6. Shadowing Summary & Recommendations

Summary of Observations

Recommended Strategies & Supports

Follow-Up Actions / Collaboration Notes

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