SHINE: SPECIAL NEEDS
INTAKE FORM
Thank you for taking the time to fill out this form. We respect your family's privacy and will only use this informtion for ministry purposes. Please answer the questions below that apply to your child in order that we may best serve your family.
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Diagnosis/Medical Condition/Disability/Learning Difference:
*
Behavioral Tendencies:
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Shy
Tantrums
Stimming
Biting
Other
How do you handle behaviors? (calming strategies)
*
Communication Skills:
*
Nonverbal
Verbal
Communicative Device
Other
Care Information:
*
Special diet
Allergies
Assistance with eating
g/tube
Will choke
Drinks with assistance
Needs a special cup
Must use straw
Needs help in restroom
Wears diapers
Has meltdowns
Elopement
Will hit
Can be aggressive
Sensory issues
Medical issues
Does your child have a favorite toy or item to carry?
Things/Activities my child LIKES:
Things/Activities my child DISLIKES:
Things my child can do independently:
Things my child can NOT do independently:
Does your child require a mobillity device?
I understand at times my child may have the opportunity to be in other areas of the church. It would be a blessing for them to have:
A trained buddy
Opportunities for inclusion
Mentoring
Structure
Self-contained classroom for structure/safety
Other
Do you authorize non-crisis intervention? De-escalating behaviors and/or holds as a last resort if your child injures self or others?
Yes
No
Please provide any other information that you think would be helpful for us to better assist your child and his/her needs:
Parent/Guardian Name:
*
First Name
Last Name
Parent/Guardian Cell Number:
*
Please enter a valid phone number.
Parent/Guardian Email:
*
example@example.com
Parent/Guardian Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: