Work Entry

First Name

Last Name

Pronunciation

Gender

Birthdate

/ /

Emergency Contact Information

In emergencies, sharing critical medical and behavioral information, including allergies, medications, and specific crisis procedures, is essential for the individual's safety. Please ensure we have all relevant details for a swift and effective response.

Parent First Name

Parent Last Name

Phone

Address

Diagnosis (Check all that apply)

Allergies or Food Sensitivities or Food-Related Behaviors?

Communication Needs (Check all that apply)

Is there anything regarding communication needs that you would like to share with us?

Mobility Needs (Check all that apply)

Is there anything regarding mobility needs that you would like to share with us?

Toileting Needs (Check all that apply)

Medical or Special Precautions

Medical Plans

What is wonderful about your child?

Interests/Activities your child may like

On their worst day, what do his/her maladaptive or negative behaviors look like? What do their typical, everyday behaviors look like?

IEP or BIP

If you are willing, please email your child's IEP or BIP to our Adaptive Program Director Lauryn Gerard .

Behavioral management plan

What are things we can do to show your child we care? Select all that apply.

If Other, please list ways that we can show we care.

My child becomes upset when...(please list ALL potential triggers or sensitivities)

My child needs encouragement to...

My child loves when...

My child does not enjoy...

My child is able to be calmed by...

Final thoughts - Is there anything else you would like to share with us?

Submit