Full Name
*
First Name
Last Name
Special Needs Family Details:
Phone Number
*
E-mail
example@example.com
Address
Street Address
Street Address Line 2
City/Town/Village
District
Postal / Zip Code
What is your relationship to the child/youth/young adult/adult
Parent
Caregiver
Aunt/Uncle
Grandmother
Sibling
Friend of Family
Applying for Myself
Other
If you chose other, please explain
How old is your child/youth/young adult/adult?
Please Select
10-12 months
1-2 years
2-3 years
3-4 years
4-5 years
5-6 years
7-8 years
8-9 years
9-10 years
10-15 years
15-20 years
20-30 years
30+
Sex of child/youth/young adult/adult
Male
Female
Name of School or Day Care
*
If he or she is not in school or day care,what does he or she do most days:
stay at home
work
go with parent or caregiver to work
stay with family or friends
Other
If you chose other, please explain
Has he or she gotten an evaluation/diagnosis?
Please Select
yes
no
in process
If so, what is the diagnosis?
Autism Spectrum Disorder Level 1
Autism Spectrum Disorder Level 2
Autism Spectrum Disorder Level 3
ADHD
Language Delay
Down Syndrome
Cerebral Palsy
Intellectual Disability
Visual Impairment
Hearing Impairment
Learning Disability
Speech and Language Disorder
Traumatic Brain Disorder
Seizures
Developmental Delay
Other
If you have not gotten an assessment done, why not?
I am waiting until my child is older
Financial Constraints
I do not know where to go or what to do
I am not ready to have my child diagnosed
Other
If you chose other, please explain
What is the primary language spoken at home?
English
Creole
Spanish
Garifuna
Maya
Other
If you chose other, please explain
Do you also speak a second language at home?
Yes
No
Yes, but rarely
What is the second language?
English
Creole
Spanish
Garifuna
Maya
Other
If you chose other, please explain
Is your child currently receiving therapy of any kind?
Yes
No
No, but I am getting Parent Coaching
Has your child ever gotten therapy?
Yes
No
Only when specialists visit on occasion
Only a few times (6-12 sessions)
What are your priority developmental concerns, if any?
speech
potty training
dressing him/herself
learning delay
writing skills
reading skills
making friends
social skills
puberty
playing with toys
playing with others
gross motor skills (climbing stairs/ladder jumping with two feet, riding a bike, etc)
fine motor skills (buttoning clothes, holding small items, cutting with scissors, etc)
Other
If you chose other, please explain.
What are your behavioral concerns, if any?
potty training
temper/meltdowns
sleep problems
feeding issues
self-injurious behaviors
attention
hyperactivity
aggression
inability to make friends
keeping clothes on in public
doesn't want to interact with others
Other
If you chose other, please explain.
What are your priority emotional concerns, if any?
anger issues
impatience
depression
anxiety
aggression
Other
If you chose other, please explain.
What are your other priority concerns?
life skills development
sensory issues
school placement
what to do after elementary school
what to do after high school
job placement
social skills
puberty
Other
Please tell us any other relevant concerns or information:
How did you hear about us?
*
Please Select
Facebook
Website
Instagram
A Friend
School
NaRCIE
Doctor
Other (Please specify...)
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