SPECIAL NEEDS & CONSIDERATIONS INTAKE FORM

Thank you for taking time to complete this form as thoroughly as you can regarding your child’s needs. We desire to serve you and your child by knowing as much as possible about their needs and how we can work to make their experience at Ogletown as positive and as helpful as possible.

Completed by:

First Name

Last Name

Date

YYYY

Relationship to child:

Phone

(###)

###

####

Child's Name

First Name

Last Name

Parent(s)' Name(s):

My child has the following diagnoses, medical condition, or learning difference:

My child has the following allergies and/or food sensitivies:

My child's main mode of functional communication is:

The goals I have for my child's development this coming year include (behavioral, social, academic, etc.)

My child has the following area(s) of interest:

My child can do these things independently:

My child needs assistance with:

My child is uncomfortable with or has an aversion to:

A trigger-point for resistance, frustration, or behavioral problem may emerge for my child when:

When/if my child experiences a period of frustration, he/she clams when we:

Doing/seeing/experiencing this one thing is an important part of my child's routine:

Does your child enjoy music?

Yes

My child seems most relaxed in settings....

Alone

With a few children

With many children

Would your child enjoy a large group worship experience?

Yes

My child is really picky about:

Please explain what your child may be communicating when exhibiting certain behaviors listed below:

My child is prone to seizures:

Yes

My child's behavior may indicate a medical problem requiring immediate attention when:

Is there any other information you would like us to know about your child?