Special Needs Intake Form (Children)
Child's First and Last Name
Date of Birth
School Grade
-- None --
Nursery 1 (0-12mths)
Nursery 2 (13mths-2yrs)
Preschool 2
Preschool 3
Preschool 4
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Graduated
Allergies
Parent's First and Last Name
Parent's Contact Information
Child's Diagnosis
Communication (if applicable): Help us understand how your child communicates. Are they speaking or non-speaking? Do they us an AAC device? Do they use sign language? Etc.
Dietary (if applicable): Please tell anything we need to know as far as food preferences, how they eat, or special preferences.
Toileting (if applicable): Is your child toilet trained? What type of assistance do they need? Do they wear a brief/diaper, or are there any special requests for toileting or do they need reminders while at church?
Fine and Gross Motor Skills (if applicable): Explain if your child is ambulatory, non-ambulatory, struggles with holding pencils, etc. How can we best support your child in this area?
Behavioral Skills (if applicable): Any behaviors that you think we should be aware of (hitting, kicking, biting, etc), when they typically take place, who they typically take place around, etc.?
Behavioral Tips (if applicable): What do you typically do when certain behaviors occur? Do they have some type of behavior plan in place either at home or school? What should be done in these situations?
Likes & Dislikes: Please tell us if your child has any special interests so that we can possibly include those in our sensory bags. Suggestions for ways to connect with child are great too! And, is there is anything we should avoid?
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