Special Needs Intake Form

Best time to contact you:

Best time for an evaluation:

How did you hear about our program?

What is your child's specific diagnosis?

Does your child have IEP?

My child is: (select one)

Does he/she need assistance with any of the following?

How does your child communicate?

If your child is non-verbal, what form of communication is used?

Describe any special medical needs or allergies that we should know about.

Are there any special accommodations necessary for physical disabilities?

Has your child participated in any other recreational activities?

If yes, please list:

What are your goals for your child in our program?

How would you describe your child’s personality?

Is there anything else that you would like to share about your child?