Special Needs Intake Form
Parent/Guardian's Email Address:
Parent/Guardian's Cell Phone:
Child's Date of Birth:
School Child Attends:
Siblings that attend Hope Kids:
Please list allergies.
Child's Specific Diagnosis/Disability:
Does your child have any physical needs?
Other physical needs
Please describe physical needs.
Does diagnosis affect child's learning/academics?
Difficulty with expressive language
Other learning difficulties
Please describe learning difficulties.
Tell us about your child 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.
Soothing/Calming Routines or Techniques
Other soothing/calming routines
Please describe soothing/calming routines.
Child's Primary Communication Form:
Uses visual cues for communication (PECS, Visuals)
Gestures, eye gazes for communication
Describe assistive technology used.
Bathroom assistance needed
Please describe restroom needs.
Needs prompts to eat
Diet restrictions (gluten free, texture restrictions, etc)
Please no snacks/food
Other eating concerns
Please describe diet restrictions.
Please describe other eating concerns
How did you hear about Hope Special Needs?
Name of Person:
Additional helpful information
Hope's special needs coordinator will be in touch to help create the optimal program for your child at Hope Church. We strive to create safe environments where your child can thrive and grow in their faith. Please choose your preferred way of contact.
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