Get Easterseals Personal Information 2019-2025

Filling out the Easterseals Personal Information form is an essential step in ensuring that the necessary information is collected for your child’s care. This guide provides you with clear, step-by-step instructions to assist you in completing this form accurately and efficiently.

Follow the steps to complete the Easterseals Personal Information form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by filling in the child's name. Include the last name, first name, and middle initial. If your child prefers to be called by a different name, please indicate that as well.
3. Next, provide the child's date of birth and their age. Ensure these details are accurate.
4. Indicate the child's gender and the name of the person completing the questionnaire. Include your relationship to the child.
5. Clarify your custodial relationship to the child. If applicable, make sure to note details about custody arrangements, including any agreements related to shared or sole custody.
6. Proceed to fill in the parent or guardian's address, including street address, apartment or unit number, city, state, zip code, and county.
7. Provide contact details for the parent or guardian, including mobile phone number, alternate phone number, and email address. Please indicate whether it is acceptable to leave a message or send emails.
8. Designate your preferred method of contact, choosing from options such as phone call, email, or other.
9. Add contact information for additional parents or legal guardians, if applicable, including their address and relationship to the child.
10. Fill in the child's address if it is different from that of the parent or guardian, and provide the child's phone number and email address if applicable.
11. Specify the child's preferred language and any secondary language.
12. Indicate whether the child has health insurance and provide details about the insurance, including the type and any relevant identification numbers.
13. Complete sections on the child's race or ethnicity, any barriers to care or special accommodations needed, and emergency contact information.
14. Proceed to the medical history section, detailing the child's primary care physician, recent exams, immunizations, and any medical concerns or treatments.
15. After providing required medical information, fill in the social and school background details, including the school name, grade, and any special education services received.
16. Complete the mental health history section by detailing any past or current mental health treatments and family history of mental health concerns.
17. Finally, address the reason for the visit and the types of services you are interested in. Include how you learned about the clinic, if applicable.
18. Review all information provided for accuracy, then save any changes, download, print, or share the completed form as needed.

Complete the Easterseals Personal Information form online today to ensure that all necessary information is submitted for your child's care.