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PDD Intake Form

PDD Intake Form (1)

Demographics & Administrative

Immediate Family Contacts
Name / Relationship / Phone
Interpreter Needed(Required)
Address / Current Residence

Complex Needs Profile

Indicate applicable areas

Non-Complex Needs Profile (check all that apply)

Non-Complex Indicators

Summary Classification

Overall presentation(Required)

Current Professional Contacts

Professional Contacts
Type / Name / Phone / Email

Medical / Health / Wellness Information

Last Medical
Last Dental
Last Optical
Current Medical Conditions
Include 'pending diagnosis' where applicable.
Assessments / Evaluations

History of Suicidal Behaviour

History of suicidal thoughts or attempts?

Risk & Safety Screening

Will a safety plan be required?

Family History

Approved Family Members (contact permitted)

Social Supports

Approved Social Supports (contact permitted)

Day Program / Employment / Volunteering / Education

Currently involved in a day program / work / volunteering?

Adaptive Functioning & Environmental Support Strategies

Legal Involvement

Guardian Input

Daily Living & Independence Skills

Quality of Life Domains (0–3 scale)

Home & Daily Living (0–3)
Community Inclusion & Participation (0–3)
Health & Well-Being (0–3)
Safety & Security (0–3)
Relationships & Social Supports (0–3)

Abuse Prevention, Safeguards & Rights

Informed of rights & complaint process?
Informed of rights re: abuse prevention, dignity, respect?
Informed of duty to report suspected/actual abuse?
Informed of Critical Incident Reporting process?
Confidentiality & information-sharing explained?
CarePros safeguarding responsibilities explained?
Informed consent signed by all parties?

Review & Signatures

Review checklist
Specialized Community Supports (if required/approved)
Procedures / Assessments

Land Acknowledgement for Treaty 6

Land Acknowledgement for Treaty 6​

CarePros respectfully acknowledges that we are located on Treaty 6 territory, a traditional meeting grounds, gathering place, and travelling route for diverse Indigenous peoples including the Cree, Blackfoot, Metis, Nakota Sioux, Iroquois, Dene, Ojibway/ Saulteaux/Anishinaabe, Inuit, and many others whose histories, languages, and cultures continue to influence our vibrant community.

We acknowledge all the First Nation, Metris and Inuit whose footsteps have marked these lands for generations. We are grateful for the traditional Knowledge Keepers and Elders who are still with us today and those who have gone before us. We recognize the land as an act of reconciliation and gratitude to those whose territory we reside on or are visiting.

All of us who live and work here benefit from the signing of this Treaty and have a responsibility to ensure that the spirit of Treaty 6 is honoured and respected.

CarePros respectfully acknowledges that we are located on Treaty 6 territory, a traditional meeting grounds, gathering place, and travelling route for diverse Indigenous peoples including the Cree, Blackfoot, Métis, Nakota Sioux, Iroquois, Dené, Ojibway/ Saulteaux/Anishinaabe, Inuit, and many others whose histories, languages, and cultures continue to influence our vibrant community.

We acknowledge all the First Nation, Métis and Inuit whose footsteps have marked these lands for generations. We are grateful for the Traditional Knowledge Keepers and Elders who are still with us today and those who have gone before us. We recognize the land as an act of reconciliation and gratitude to those whose territory we reside on or are visiting.

All of us who live and work here benefit from the signing of this Treaty and have a responsibility to ensure that the spirit of Treaty 6 is honoured and respected.

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