Participant Interest Form
Please complete this form with as much detail as possible. Your answers help us provide the safest and most beneficial experience for each participant. All information is kept confidential and only shared with staff involved in your care.
Parent/Legal Guardian
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Name
*
First Name
Last Name
Age
*
Gender
*
Height (feet and inches)
*
For participants 10 years and above
Weight (in pounds)
*
Primary Diagnosis
*
(e.g. Cerebral palsy, level 2-3 autism, rare genetic disorders, etc.)
Back
Next
Does the participant use any of the following?
*
Feeding Tube
Wheelchair
Walker
Braces
Orthotics
Adaptive Stroller
None
Other
Primary ways the participant communicates:
*
Verbal
Non verbal
Sign language
Communication device
Can the participant sit unassisted?
*
Yes
No
With Support
Other
Does the participant have scoliosis, hip dislocation, or any spinal/orthopedic issues?
*
Yes
No
Other
Does the participants have seizures?
*
Yes
No
Other
If yes to the above question, what type, frequency, and when was the last seizure?
Is the participate sensitive to touch, sound, or movement?
*
Yes
No
If yes to the above question, what are known triggers and helpful coping strategies?
Does the participant have shunts?
*
Yes
No
Other
Does the participant have spinal fusions or rods?
*
Yes
No
Does the participant have joint dislocations or instability?
*
Yes
No
Are there any movement limitations or pain that we should be aware of?
*
Yes
No
If yes, please describe
Does the participant have sensory impairments (vision/hearing)
*
Yes
No
If yes, please describe
Does the participant display any of the following behaviors (check all that apply):
*
Easily overstimulate
Aggression or hitting
Self injury
Bolting or running
Social anxiety or withdrawal
Difficulty with transitions or new environments
Other
What tends to trigger distress or overwhelm?
*
Our team is currently reviewing your information with great care to ensure we understand your child’s unique needs, strengths, and goals. Within the next 5–7 business days, we’ll follow up with a request for any additional information or documentation (if needed) or confirmation of program eligibility.
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