Parent(s) name
*
First Name
Last Name
Cell
*
(###)
###
####
Child/loved one’s name
*
Goes by
Birth date
*
MM
DD
YYYY
Chronological age
*
Developmental age
*
Special needs and/or medical diagnosis (e.g. AU, DS, ED, RAD, Bipolar, DSI)
I would describe my loved one as being/having (check all that apply)
If other please, describe:
My loved one responds best to (check all that apply)
*
My loved one’s normal disposition is (check all that apply)
My loved one’s favorite toy or activity is
My loved one really doesn’t like to
My loved one likes (check all that apply)
If other, please describe
Behavior challenges (check all that apply)
If other, please describe
When my loved one is unhappy, the following things might calm him/her down
Is your loved one hearing impaired?
yes
no
Method of communication (check all that apply)
If other, please describe
Social Behavior
Does your loved one have any socially inappropriate behaviors for us to be aware of? (i.e. self-arousal, aggressive, cursing etc). If so, please describe words/hand signals, (or other methods) you use to redirect:
Restroom needs (please bring necessary supplies)
How does your loved one communicate his/her need to go to the restroom?
Describe your loved one’s mobility (i.e. wheelchair, needs special support, crawls, sits alone, stands alone, walks independently, etc)
List any medical issues/related info (i.e. seizures/pre-indicators, tubes, buttons, medication changes, allergies, etc)
Any special feeding issues/needs: (i.e. feeding tubes, no solid foods, etc.)
Anything else you’d like us to know about your precious loved one/ your hopes & desires for their time with us, etc:
