Intake Questionnaire

Purpose: The Intake Questionnaire is used by the Care Navigator to gather information about the child’s development to inform the makeup of the evaluation team. The Intake Questionnaire is made up of three sections: 1) General Questions, 2) Medical 3) Developmental Questions.

1. To access the Intake Questionnaire click Launch Intake Questionnaire from the right panel on the EI Referral Case

2. General Questions - Asks basic information about why the family is calling, if their child has previously been in EI and if they attend childcare.

3. Medical: Questions regarding any medical or dental concerns and regarding hearing and vision concerns

4. Developmental Questions by the child’s age in months. Each question has a yes or no response. If response indicates a concern, then a narrative field is available to add more information

   1. Birth to 3 months

   2. 3 to 6 months

   3. 6 to 9 months

   4. 9 to 12 months

   5. 12 to 15 months

   6. 15 to 18 months

   7. 18 to 24 months

   8. 24 to 30 months

   9. 30 to 36 months

      1. If a child's age spans two age categories, questions for both age ranges will be displayed

5. To view responses to the Intake Questionnaire click Launch Intake Questionnaire

6. Link to complete Intake Questionnaire template