Child's Name
Parent/Guardian (1)
Email
Phone( ) -
Parent/Guardian (2)
Siblings
Name(s) and Age(s)
Please describe child's needs and diagnosis
Speaking
Sign Language
Picture Symbols/ Schedule
Other
Please describe
Hugs
Quiet Times
Rocking
Outdoor Activities
Singing
Lively Activities
Story Time
Arts and Crafts
Things that are comforting or calming:
Things that cause distress or should be avoided:
Favorite toys and activities:
Activities and toys that are disliked:
Wears diapers/Pull-ups
Toilet training
Needs assistance
Independent
Additional toileting information:
Needs special support
Walks independently
Sits alone
Stands alone
Wheelchair
Crawls
Prone to run
Additional mobility information:
Allergies and/or food restrictions:
Goldfish okay
Dum Dums okay
Snacks from home only
Yes
No
How do you redirect undesirable behavior? What are key phrases that help?
Current personal goals, or goals for this year at church:
Additional comments:
