Special Needs Intake | Woodlands Church

First Name

Last Name

Phone

Relationship to the child

Any custody concerns we should be aware of?

Would you like to add child's sibling information? If so, how many siblings?

Is your child in school?

Yes No

Does your child have outside therapy?

Occupational Physical Speech Other

My child loves to

Activities they enjoy: (music, art, drawing, toys, walks, technology)

What are your child’s strengths

Allergies/Food Sensitivities

Yes No

Food/drinks to avoid

Assistance needed for eating/drinking?

Yes No

Physical activity/mobility level of your child

Developmental age of your child

Is your child able to identify and regulate his/her emotions?

Please share any medical concerns your child may have (seizures, G-tube, trach, medication, other special concerns)

Toileting Needs

Independent With Assistance Wears Diapers

Signs, gestures, words to Indicate toileting needs:

Medication

Yes No

Main mode(s) of communication

Verbal Limited Speech Gestures Sign Language Picture Communication Symbols Assistive Technology

What is the main language spoken at home

My child is independent with

My child needs assistance with

My child is uncomfortable with or has sensitivities to

Behavior concerns to be aware of

Running Away Biting Scratching Hitting Temper Tantrums Aggression towards others Other

Calming tools and aids for these behaviors

Trigger-points for frustration/resistance

Behaviors that may communicate a specific need (please indicate the need where appropriate)

Reinforcers and Reward System

Praise Food Books/Toys/Games Privileges Tangible Rewards (stickers) Unsure Other

Classroom situations you wish to be contacted about

Please describe your child’s understanding of and relationship with God

Goals for your child at church

Ideas for the church to better serve your family

Additional thoughts or comments

Work Entry

Embrace Ministry Intake Form

Embracing All Needs

Parent Information

Emergency Contacts

Siblings

Child Information