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Intake Form

Welcome! We are so pleased to get to know your child, you, and your family better! The more information we know about your child, the better we will be able to share the love of Jesus with them. Please take a few minutes to complete this form.

General Information
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Cell *
Parent/Guardian Cell
Communication
Verbal / Non-Verbal *
Check all that apply… *
Can express basic needs and wants by… *
Dietary/Feeding Needs
Check all that apply… *
Seizures, G-Tube, Trach, Positioning, Respiratory
Toilet/Hygiene Needs
Check all that apply… *
Behavior
I feel my child would be most successful (check all that may apply)… *
When it is necessary, my child may take a break from the group setting and go for a walk, find a quiet and calm place or participate in a small group activity… *
Story Time, Videos, Lights, Music, Crafts (including scissors, glue, and small pieces), Gross Motor, Transitions, Small Groups, Large Groups, Peer Interactions