TC Kids Special Needs Form

Childs Name

Childs First Name

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Childs Last Name

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Nickname

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Parent's Name

First Name

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Last Name

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Address

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City

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Zipcode

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Phone

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Email

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Childs Date of Birth

Childs current Grade

Please indicate "NA" if not applicable

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Food Allergies

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Child's specific diagnosis:

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Diagnosis in laymans terms:

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How this diagnosis affects my child physically:

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How does this diagnosis affects my child emotionally:

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Is your child prone to running off?

If so what are the triggers and how do you handle it?

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Things to avoid that might "set my child off ":

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Soothing/calming routines:

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My child is sensitive to:

ex. indoor/outdoor light, loud sounds,specific textures

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My child needs extra time/patience from you concerning:

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Other helpful behavioral information:

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My childs communication is primarily:

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Please give examples or explain the communication selected from the previous question:

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Familair words/signs my child uses:

ex:ba-ba for bottle, sign for outside

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Mobility is impacted

Not at all
Mildly
moderately
Profoundly

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Eating concerns

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My child is

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My child interests include:

favorite toy, preferred activities, ect.

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Please share anything else you think might be helpful for us to know about your child:

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