Special Needs Intake - Southland Christian Church

Primary campus

Birthdate

Phone number

Medical note

Allergies:

Gender

Household members

Communication Needs: *

Verbal

Non-Verbal

American Sign Language

Communication Device

Other

Does your child have any medical concerns? If yes, please explain. *

Does your child have a history of seizure activity? If yes, please explain type and frequency. *

Please explain protocol for any medical concerns:

Toileting Needs: *

Uses toilet independently

Uses toilet with supervision

Wears diaper/pull-up

Other

List any signs or gestures that may indicate they need to use the restroom.

Behavior Concerns: *

I get frustrated when:

Loud noises

Bright light

Darkness

Being touched

Talking

I'm hungry

I'm tired

Other

List any behaviors such as biting, scratching, any aggressive nature. *

At risk for elopement?

How can we redirect any inappropriate behaviors? *

Sensory Needs: *

Touch

Sound

Light

Movement

Please Explain Sensory Needs:

Anything else we should know about your child? *

School:

Photo *

For safety reasons, please upload a photo of your child.

No file currently selected

Choose 1 file. Maximum file size 10 MB.