INTAKE & CLASS PLACEMENT FORM
Gymnastics | Tumbling | Movement Adventure | Mind & Motion Adventure
This brief intake helps us understand your child's current abilities, support needs, and experience in group settings so we can recommend the safest and most appropriate class environment. It is not a medical or diagnostic evaluation.
1. CHILD & FAMILY INFORMATION
Child's Name:
*
First Name
Last Name
Age:
*
Your Regional Center
*
San Gabriel/Pomona (SGPRC)
Easter Los Angeles (ELARC)
Orange County (RCOC)
Frank D Lanterman RC
South Central Los Angeles (SCLARC)
Inland (IRC)
Other
Is your child currently enrolled in the Regional Center Self-Determination Program (SDP)?
*
Yes
In the process of enrolling
No
Not sure
If yes - Which Financial Management Service (FMS) provider do you currently use?
ACE Financial Management Service
Ritz Financial Management Service
Aveanna
Action FMS
Other
Which program(s) are you interested in?
Gymnastics
Movement Adventure
Mind & Motion Adventure
Not sure - please recommend
2. CURRENT GROUP CLASS EXPERIENCE
Is your child currently participating in a mainstream group class or activity?
*
Yes
No
If yes, what type of class or activity?
Approximately how many children are in that group?
1-3
4-5
6-8
9-10
11+
Unsure
How does your child usually participate in that group?
Independently most of the time
Needs occasional reminders or redirection
Needs frequent adult support
Needs continuous 1:1 support
3. COMMUNICATION & GROUP PARTICIPATION
How does your child communicate? (Check all that apply)
*
Conversational speech
Short phrases / single words
AAC device
Gestures / signs
Primarily non-speaking
Your child can usually: (select all that apply)
*
Follow a 1-step direction
Follow a 2-step direction
Wait briefly for a turn
Transition between activities
Stay with the group
Participate for 30-45 minutes
Does your child need frequent 1:1 prompting to participate safely or remain with the group?
*
Rarely
Sometimes
Often
Nearly all the time
Stars Gymnastics LLC | 410 N Azusa Ave., Covina, CA 91722 | Office@Stars-Gymnastics.com
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4. MOVEMENT, SAFETY & SUPPORT NEEDS
Which best describes your child's movement abilities? (Check all that apply)
*
Crawls
Walks independently
Runs independently
Jumps with two feet
Climbs with support
Balances with support
Needs physical assistance for some activities
Uses a walker
Uses a wheel chair
Are there any physical restrictions, medical considerations, or safety concerns we should know about before participation?
*
No
Explanation
Please explain:
Does your child currently have any of the following safety support needs?
*
Elopement / may leave the activity area
Aggression toward others
Self-injurious behavior
Frequent falling / poor safety awareness
None of these
Other
Please explain:
*
During a group class or activity, does your child typically remain with the group and within the designated activity area?
*
Yes - typically stays with the group/activity area independently
Usually - may wander or move away occasionally but responds to verbal redirection
Sometimes - may leave the group/activity area and requires frequent redirection or close supervision
No - may unexpectedly run, walk away, or leave the designated activity area and requires continuous close supervision
I'm not sure / child has not participated in a group setting
Please tell us more about when your child may leave the group or activity area and what helps them return safely. For example: Does this happen when they are excited, distracted, overwhelmed, seeking something of interest, avoiding an activity, or for another reason? What type of prompting or assistance is usually needed?
*
When your child becomes overwhelmed, frustrated, or overstimulated, what usually helps?
*
5. SUPPORT LEVEL & CLASS PLACEMENT
Does your child currently receive support from an aide, parent, therapist, or other 1:1 support person during group activities?
*
No
Sometimes
Yes, regularly
Based on your child's current group experiences, what level of support seems most successful?
*
Standard group (up to 8-10 children)
Small group (up to 5 children)
Very small group (up to 3 children)
1:1 instruction
Unsure - please recommend
Would a parent/caregiver be available to assist during class if needed for safety or successful participation?
*
Yes
No
Possibly
What assistance does your child need when he/she needs to use the restroom?
*
No assistance needed
Verbal prompting only
Assistance dressing/undressing
Full assistance from beginning to end.
6. Tell us more
Please share any strengths, interests, motivators, triggers, or strategies that help your child feel successful in a class setting.
*
What is your availability for a Meet & Match Meeting?
We will call or text you to finalize your Meet & Match meeting date and time.
Your availability for a Meet & Match (Select all that apply)
*
Rows
Saturday
9:25 am
10:00 am
10:40 am
12:10 pm
1:10 pm
Parent/Guardian Name:
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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