Special Needs Intake Form

If you or a friend/family member has special needs, please complete this intake form. It is our desire to serve you and your family, and this form will be instrumental in equipping us to best do so.

Galatians 6:2

Name of Individual with Special Needs

Address

Phone

DOB

Grade, if applicable

Diagnosis

Name of Parent/Guardian

Address

Phone

This address will receive a confirmation email

Does our Special Needs Friend live at home with you?

Please select all that apply.

Yes No

If not, where does he/she live?

Siblings Name & Ages

Does he/she enjoy music?

Please select all that apply.

Yes No

Does he/she enjoy arts & crafts?

Please select all that apply.

Yes No

Does he/she enjoy outside activities?

Please select all that apply.

Yes No

Does he/she enjoy writing?

Please select all that apply.

Yes No

Does he/she enjoy reading?

Please select all that apply.

Yes No

Does he/she have any food allergies or sensitivities?

Please select all that apply.

Yes No

If yes, please explain

Is he/she prone to seizures?

Please select all that apply.

Yes No

Other medical concerns

Toileting Needs

Please select one option.

Independent Independent with assistance Wears diapers

Signs, gestures, words to indicate toileting needs

Medication

Please select all that apply.

Yes No

If yes, type and purpose

Main mode(s) of communication

Please select one option.

Verbal Visual Supports Sign Language Digital Devices

Does he/she have any discomfort or sensitivities to anything specific? If so, please explain.

Does he/she have any behavior concerns we should be aware of? If yes, please explain.

Does he/she have any trigger points for frustration/resistance? If so, please explain

Are there any calming tools and/or aids we should be aware of?

If our Special Needs Friend is under 18, are there any classroom situations you wish to be contacted about? If so, please explain.

Please describe our Special Needs Friend's understanding of and relationship with God.

Do you have any specific goals for our Friend while at church?

Suggestions for how our church can best serve you and your family.

Additional thoughts or comments

Special Needs Intake Form

Description

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