Outcomes, Assessment Services, & Intervention Supports (OASIS) - Youth Client Intake - Part 3

Please provide the following information for our records. Leave any questions you prefer not to answer blank.

This website uses cookies and other technologies to improve the functionality and performance of this site and your experience. Learn more by reviewing our Privacy Policy.

Person completing this form:

First Name

Last Name

Is the person completing this form a guardian?

Relationship to child

Relationship to child (other)

Phone

- -

Please enter the first guardian's email address

Address

Street Address

City

State

Zip

Child

First Name

Last Name

Birthdate

format: MM-DD-YYYY

Age

Gender

Preferred Pronouns

When learning to read, did your child have difficulty…

… hearing rhymes or distinguishing sounds in words?

… learning letters of the alphabet?

… learning sounds that go with letters?

… sounding out words?

… spelling correctly?

… learning sight words?

… reading quickly and easily?

… learning vocabulary words?

… understanding what they read?

When learning math, did your child have difficulty…

… learning names of numbers?

… learning how numbers are related to each other (e.g., counting by 10s)?

… memorizing basic math facts (e.g., 3 x 4)?

… quickly solving simple math problems?

… solving math problems without using fingers?

… apply math skills to real-world problems?

… copying math problems accurately?

… remembering math vocabulary or concepts?

… learning procedures to solve math problems?

… remembering how to solve problems over time?

When learning to write, did your child have difficulty…

… forming letters accurately or with handwriting?

… learning how letters and sounds go together?

… learning fine motor skills?

… getting their thoughts down on paper?

… structuring sentences correctly?

… writing easily and quickly?

… organizing what they are writing?

… copying simple shapes or pictures?

… drawing pictures?

In the area of cognitive skills, did your child have difficulty…

… understanding language or expressing him/herself?

… remembering multistep directions?

… completing simple tasks quickly and easily?

… remembering how to complete new tasks the next day or week?

… retrieving words or ideas easily from memory?

… solving novel problems or using logical reasoning?

… visualizing things, or with directions?

… distinguishing speech sounds?

… shifting or transitioning from one task to another?

… planning ahead or organizing/prioritizing tasks?

… monitoring his/her work for mistakes?

… getting started on tasks, knowing how to start something?

Master’s and doctoral students in our graduate programs staff Outcomes, Assessment Services, & Intervention Supports (OASIS). To ensure quality of services you receive, all counselors in training are assigned faculty supervisors with whom to consult concerning the process of counseling. Your session may be both audio and video recorded. The purpose of recording is to provide instruction and feedback to students. All recorded materials and written records are restricted to the internal use of the OASIS and their confidentiality will be strictly safeguarded, with expectations discussed with your counselor in the first session. Recordings are delated after each semester.