Registration Form | Lumaris Support Serv

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Pre-Assessment & Intake Form

A brief form to help Lumaris understand the participant’s needs and prepare for a focused Virtual Assessment.

Participant full name*

Participant date of birth*

City and postal code e.g. Vancouver, V5K 0A1*

Parent/guardian or primary contact name*

Relationship to participant*

Phone number*

What are you interested in?*

Lumaris Day Programs (In-Person)

Lumaris Connect Class (Virtual)

Lumaris Math Club

In-Home Support

Community Participation

Respite / Relief Support

Other

Preferred virtual assessment date & time*

Time*

Email address for virtual meeting link*

Lumaris will confirm the appointment and send the Google Meet link by email.

Support level

Mostly independent

Occasional prompting

Regular support

Significant/direct support

1:1 support

Varies by situation

Diagnosis / support needs

Independence & support

Communication

Behaviour & triggers

Safety

Current services & supports

Current activities

What works well?

Goals

Important considerations

Preferences

Additional information

Emergency contact name and phone number*

Completed by*

I confirm that the information provided is accurate and understand that this form is a pre-assessment guide and does not replace the Virtual Assessment conducted by Lumaris Support Services Inc.*

Next Steps

You’re almost done. Just a few quick steps remain.

Ready for Your Assessment

Our team will review your intake and get you ready for your virtual assessment.

Book Your Assessment

CLICK HERE: Book Your Virtual Assessment Session Now.

Home
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Registration Form

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