TC Kids Special Needs Form

Childs Name *

Childs First Name

Childs Last Name

Nickname *

Parent's Name *

First Name

Last Name

Address *

City

Zipcode

Phone *

Email *

Childs Date of Birth *

YYYY

Childs current Grade

Please indicate "NA" if not applicable

Food Allergies *

Child's specific diagnosis: *

Diagnosis in laymans terms: *

How this diagnosis affects my child physically: *

How does this diagnosis affects my child emotionally:

Is your child prone to running off?

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

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

Soothing/calming routines: *

My child is sensitive to: *

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

My child needs extra time/patience from you concerning:

Other helpful behavioral information:

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: *

Familair words/signs my child uses:

ex:ba-ba for bottle, sign for outside

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 *

My child interests include: *

favorite toy, preferred activities, ect.

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

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