Special Needs/Additional Support Intake Form
As part of our enrollment process, we ask parents of children who may need additional support to complete this intake form. Please complete this intake form with the child's, medical, educational, support, and contact information. All fields are optional unless the source indicates otherwise. This form will be used to assess your child’s individual needs during the enrollment process so we can determine if our program can best support a safe and successful experience for your child.
Child and Contact Information
Child/Individual’s Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
Please Select
Male
Female
Primary Guardian
First Name
Last Name
Primary Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Guardian Email
example@example.com
Medical and Health Information
Primary Diagnosis
*
Additional Diagnoses
Diagnosing Physician / Professional
Current Medications
Allergies
Assistive Devices Used
Wheelchair
Walker
Braces
Communication Device
Hearing Aids
Other
Communication Abilities
*
Verbal
Non-verbal
Uses Sign Language
Uses Communication Device
Limited Speech
Other
Primary Language Spoken at Home
Other Languages Spoken
IEP or 504 Plan in Place
Please Select
IEP
504 Plan
Both
None
Unsure
Sensory Sensitivities
*
Noise
Light
Touch
Crowds
Smells
Other
Mobility / Physical Limitations
Toileting Needs
*
Please Select
Independent
Needs Some Assistance
Fully Dependent
Uses Diapers / Pull-Ups
Uses Catheter / Other Medical Support
Feeding / Eating Needs
Dietary Restrictions
Seizure History
Please Select
No History
History of Seizures (controlled)
History of Seizures (uncontrolled)
Seizure Description and Protocol
Other Medical Conditions
Educational and Support Services
Educational/Program Setting
*
Please Select
Early Intervention
Preschool
Elementary School
Middle School
High School
Transition Program
Home School
Other
Current School/Program Name
Grade/Level
Areas of Strength
Areas of Need/Concern
Behavioral Considerations
Preferred Calming Strategies
Current Therapies/Services
Speech Therapy
Occupational Therapy
Physical Therapy
Behavioral Therapy/ABA
Counseling/Psychology
Special Education
Social Skills Group
Tutoring
Other
Therapist/Provider Names and Contacts
Goals for Enrollment/Participation
Additional Information or Special Instructions
Consent to Obtain/Share Information with Other Providers
*
Yes, I consent
No, I do not consent
Signature
Parent/Guardian Signature
*
Date of Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: