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TC Kids Special Needs Form
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* Required
Childs Name
*
Childs First Name
Your answer
Childs Last Name
Your answer
Nickname
*
Your answer
Parent's Name
*
First Name
Your answer
Last Name
Your answer
Address
*
Your answer
City
Your answer
Zipcode
Your answer
Phone
*
Your answer
Email
*
Your answer
Childs Date of Birth
*
MM
/
DD
/
YYYY
Childs current Grade
Please indicate "NA" if not applicable
Your answer
Food Allergies
*
Your answer
Child's specific diagnosis:
*
Your answer
Diagnosis in laymans terms:
*
Your answer
How this diagnosis affects my child physically:
*
Your answer
How does this diagnosis affects my child emotionally:
Your answer
Is your child prone to running off?
If so what are the triggers and how do you handle it?
Your answer
Things to avoid that might "set my child off ":
*
Your answer
Soothing/calming routines:
*
Your answer
My child is sensitive to:
*
ex. indoor/outdoor light, loud sounds,specific textures
Your answer
My child needs extra time/patience from you concerning:
Your answer
Other helpful behavioral information:
Your answer
My childs communication is primarily:
*
Verbal
Verbal & speaks clearly
Non-Verbal
Requires clues to initiate
Uses assistive technology
Uses eye gazes to communicate wants/needs
Signs
Please give examples or explain the communication selected from the previous question:
*
Your answer
Familair words/signs my child uses:
ex:ba-ba for bottle, sign for outside
Your answer
Mobility is impacted
*
Not at all
Mildly
moderately
Profoundly
My child
Uses a walker
Uses a wheelchair
Uses crutches
Falls easily
N/A
Clear selection
Eating concerns
*
Self feeds easily
Needs prompts to eat
Requires supervision/assistance
Uses special utensils
Uses a G-Tube
Other:
My child is
*
Choose
In diapers
Is potty training
Requires supervision/assistance in bathroom
Toilets independently
My child interests include:
*
favorite toy, preferred activities, ect.
Your answer
Please share anything else you think might be helpful for us to know about your child:
Your answer
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