The Special Needs Dayhab Initial Contact Form

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Student's First Name *

Student's Last Name *

Student's Age *

Student's Gender *

Guardian's First Name *

Guardian's Last Name *

Guardian's Phone Number *

Guardian's Email Address *

What is your child's diagnosis? *

Is your child bathroom independent? *

Yes

Is your child verbal? *

Yes

Is your child able to follow simple instructions? *

Yes

Is your child able to participate in small group activities such as crafts or paints? *

Yes

Is your child able to go to a restaurant and eat with a small group? *

Yes

Is your child able to interact with other special needs young adults without any behavioral issues, aggression towards others, or self-injurious behaviors? *

Yes

I would like my child to attend the following: *

5 days a week

4 days a week (Monday, Tuesday, Wednesday, Thursday)

2 days a week (Monday and Wednesday)

2 days a week (Tuesday and Thursday)

The Special Needs Dayhab does not accept state money, so private pay is expected. Do you have the financial resources to pay for the program? *

Yes

Questions or Comments?

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