Parent/Guardian Questionnaire for Adults With Special Considerations
This form has been created to help us get to know your loved one a little & to try to ensure that they have a good & safe experience here at Southcrest. We ask that you fill this form out before your first visit, if at all possible. If you would like to have a tour before your first visit, please contact Sharla Tyson at sharlat@southcrest.org.
Form Completed By: *
Your answer
Date *
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Participant Name: *
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Date of Birth: *
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Parent/Guardian Name, Phone, & Address: *
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Participant has the following diagnosis, medical condition , or learning difference: *
Your answer
Allergies and/or food sensitivities: *
Your answer
Main mode of functional communication is: *
Your answer
Participant has the following areas of interest:
Your answer
He/she can do these things independently:
Your answer
Needs assistance with: *
Your answer
Is uncomfortable with or has an aversion to: *
Your answer
A trigger-point for resistance, frustration, or behavioral problems may emerge when: *
Your answer
When/if participant experiences a period of frustration, he/she calms when we: *
Your answer
Doing/seeing/experiencing this one thing is an important part of participant's routine:
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Does he/she have seizures? *
He/she seems most relaxed in this setting: *
Would participant enjoy a large group worship experience? *
Participant is really particular about: *
Your answer
Participant may be trying to communicate their need for _______ (describe) when he/she exhibits the following behavior: *
Your answer
Participant's behavior may indicate a medical problem requiring immediate attention when: *
Your answer
Some of participant's favorite snacks and drinks are:
Your answer
He/she needs the following food modification: *
Your answer
Participant's strengths are:
Your answer
Other information you would like for us to know:
Your answer
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