Hope Students Special Needs Intake Form
Parent/Guardian's Email Address:
Parent/Guardian's Cell Phone:
Student's Date of Birth:
School Student Attends:
Please list allergies.
List any siblings that attend Hope. (Names and ages)
Student's Specific Diagnosis/Disability:
Does your student have any physical needs?
Other physical needs
Please describe physical needs.
Does diagnosis affect student's learning/academics?
Please describe learning difficulties.
Tell us about your student socially/emotionally/behaviorally? (Check all that apply)
Prefers to play alone
Prefers playing with others
Plays well in large groups
Adapts well to new situations
Sometimes hits, bites, or hurts self/others
Adapts to new situations with difficulty
Sometimes attempts to run away
Responds well to correction
Hyperactive and/or ADD
Responds to correction with difficulty
Difficulty with transitions
Needs constant structure
Needs adult assistance to participate in lessons/activities
Uses a visual schedule
Other social/emotional/behavior needs
Please describe social/emotional/behavior needs.
Please describe situations that may trigger your student to have challenging behaviors.
List positive distractors to deescalate challenging behaviors.
Describe soothing/calming techniques.
Describe motivational techniques that are used to help your student.
Student's Primary Communication Form:
Uses visual cues for communication (PECS, Visuals)
Gestures or pointing
Describe assistive technology used.
Bathroom assistance needed
Please describe restroom needs.
Feeding Needs/ Support:
Needs prompts to eat
Diet restrictions (gluten free, texture restrictions, etc)
Other eating concerns
List foods that your student will eat and any foods to avoid for your student:
Additional helpful information
A special needs coordinator will be in touch if any follow-up is needed. Please choose your preferred way of contact.
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