Special Needs Intake Form Best time to contact you: Best time for an evaluation: Morning Afternoon (before 5pm) Evening (after 5pm) How did you hear about our program? What is your child's specific diagnosis? Does your child have IEP? Yes No My child is: (select one) High Functioning Moderate Low Functioning Does he/she need assistance with any of the following? Walking Remaining with a group Grasping/manipulating objects Toileting Listening/following directions Other How does your child communicate? Verbal Nonverbal 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? Yes No 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?