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Speller Intake Form

Thank you for taking this step with us. The information below helps Sunny, your practitioner, understand your child's strengths, history, and goals so she can support them well from day one.

Sunny, True Vine Mission Practitioner
Meet Your Practitioner

Sunny

Sunny will be reviewing your responses and working directly with your family to get started. Feel free to share anything that will help her get to know your child.

👤 New Speller Demographics

Primary Contact
Secondary Contact (Optional)

🏃 Motor Skills Inventory

Please describe your child's current motor profile. Descriptions could include walking, running, pincer grasp, writing, typing, following directions, and toilet function. Be sure to highlight strengths!

✍️ Spelling History

What method(s) have they received training in? Does your child work with a local provider — if so, who?
What level of training have you received as a communication partner (if any)?
If your child has spelling experience, how long have they been spelling? Are they open or fluent with any providers or communication partners? Describe their current level of open communication or fluency.
What are 2 goals you have for your speller's program? Please be as specific as possible.

🌿 Sensory Processing Inventory

Please describe his/her sensory profile. Is s/he sensory-seeking or sensory-defensive, and for which senses? Consider visual, auditory, tactile, taste/smell, movement (vestibular), heavy work (proprioception), and interoception (sensing internal states, e.g. feeling "full" after a meal).

💛 Social & Emotional Inventory

What are his/her current supports within differing environments (i.e. school)?
Descriptions could include frustration tolerance, impulse control, challenging behaviors, triggers, and calming inputs.

🩺 Medical History

If applicable — how long has your child been on the current regimen, and do you feel it's a good fit?
Vision therapy, PBM, EEG, Brain Balance, primitive reflex therapy, NMT, etc. Any relevant results to share?
Please list any allergies and the associated reaction.

🎥 Speller Video

Please share a link to a clip of your son/daughter spelling to communicate (if already using a form of AAC), or any clip of them engaged in an activity or moving their body. A shared Google Drive, YouTube (unlisted), or Dropbox link works well.

❓ Initial Questions

What question(s) would you like Sunny to address right at the start of your sessions?

🖊️ Consent & Signature

I authorize True Vine Mission to collect and retain the health and medical information provided on this intake form, including but not limited to seizure history, current medications, and relevant diagnoses. This information will be used solely to ensure the safety and appropriateness of services provided. It will be kept confidential, shared only with staff and practitioners directly involved in my child's care, and will not be disclosed to third parties without my written consent except as required by law. I understand that providing this information is voluntary, but that certain details may be necessary to participate safely in the Spellers Method program through True Vine Mission.

Your responses are kept confidential and shared only with staff and practitioners directly involved in your child's care.

Thank You 🎉

Your intake form has been received. A member of our team will reach out to you shortly to schedule next steps.