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Intake Form
Caring for Those with Special Needs
Your name
*
Last name
Email address
*
Child's Name:
*
Child's DOB:
*
Child's Age:
*
Diagnosis:
*
Father's Name, Address, Phone, and Email:
*
Mother's Name, Address, Phone, and Email:
*
Please list siblings names:
My child loves to:
*
Enjoys music?
Yes
No
Enjoys outside play?
Yes
No
Enjoys arts and crafts?
Yes
No
Allergies/Food Sensitivities:
*
Yes
No
Please list any other medical concerns we should be made aware of?
Restroom Assistance:
*
Independent
Needs Assistance
Wears Diapers
Main mode of communication:
*
Verbal
Visual Supports
Sign Language
Digital Devices
My child is uncomfortable with or has sensitivities to:
Behavior concerns to be aware of:
Trigger points for frustration/resistance:
Calming tools/aids:
Goals for your child at church:
Ideas for the church to better serve your family:
Submit
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