Name

First Name

Last Name

Nickname

Parent(s) Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email Address

Date of Birth

YYYY

My Child's Current Grade (If Applicable)

Specific Details

My Child's Specific Diagnosis:

Diagnosis in Layman's Terms:

How This Diagnosis Affects My Child Physically:

How This Diagnosis Affects My Child Emotionally:

Is Your Child Prone to Eloping/Running Off? If So, What Are The Triggers and How Do You Handle It?

Things To Avoid That Might "Set My Child Off":

Soothing/Calming Routines:

My Child Is Sensitive To (ex. Indoor/Outdoor Light, Loud Sounds, Specific Textures):

My Child Needs Extra Time/Patience From You Concerning

Other Helpful Behavioral Information:

My Child's Communication Is Primarily:

Communication

Please Give Examples Or Explain The Communication Selected From The Previous Question:

Familiar Words/Signs My Child Uses (ex. Ba-Ba For Bottle, Sign for Outside)

Mobility

Mobility Is Impacted

My Child

My child is

Please note that parents will be called to take their child to the bathroom if assistance is needed. Our staff is prepared change diapers up to age 3.

Miscellaneous

My Child's Interests Include: (Favorite Toy, Preferred Activities, Etc.)

Please Share Anything Else You Think Might Be Helpful For Us To Know About Your Child: