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 *
MM
/
DD
/
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: *
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 *
My child
Clear selection
Eating concerns *
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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