Intake Form – Brilliant Beyond Measure

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BBM Connect Family Needs Assessment

Helping Families Navigate Every Step—from Diagnosis to Daily Living.

Welcome to BBM Connect, a program of Brilliant Beyond Measure. Whether your child has recently received a diagnosis or you’ve been navigating this journey for years, we’re here to help. This intake allows us to better understand your family’s needs so we can connect you with appropriate resources, programs, and support.

⏰ Estimated completion time: 5–10 minutes

1. Parent / Guardian Information

Full Name

Relationship to Child

Email Address

Phone Number

Preferred Method of Contact

Phone Email Text Message

2. Child Information

Child's First Name

Child's Age

City

County

3. Diagnosis Information

Has your child received a diagnosis?

Yes No Currently Being Evaluated

If yes, what diagnosis has your child received?

Approximately when was your child diagnosed?

4. How Can We Support Your Family?

Please select all that apply.

Newly Diagnosed Support Understanding Autism IEP / School Advocacy Regional Center Services IHSS Guidance ABA Information Speech Therapy Resources Occupational Therapy Resources Behavioral Support Resources Parent/Caregiver Support Community Events Workshops Financial & Community Resources Respite Resources Other

5. Tell Us About Your Child

What are your child's greatest strengths?

What challenges is your family currently experiencing?

What goals do you have for your child over the next 6–12 months?

6. Current Services

Please select all services your child currently receives.

None Regional Center ABA Therapy Speech Therapy Occupational Therapy Physical Therapy School Special Education Services Counseling Social Skills Program Other

7. How Did You Hear About Brilliant Beyond Measure?

Friend or Family Social Media Regional Center School Medical Provider Community Event Internet Search Other

8. Additional Information

Is there anything else you would like us to know about your child or your family's journey?

9. Stay Connected

I would like to receive information about:

Parent Workshops Community Events Family Meetups Educational Resources Volunteer Opportunities Monthly Newsletter

10. Consent

I certify that the information provided is accurate to the best of my knowledge.

I understand that submitting this form is a request for support and does not establish a medical, therapeutic, legal, or professional client relationship with Brilliant Beyond Measure.

I consent to Brilliant Beyond Measure contacting me regarding programs, services, resources, and follow-up related to this intake.

Brilliant Beyond Measure

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