Special Needs Ministry Intake Form

We desire to provide a welcoming environment for all of our kids to find and follow Jesus. Please fill out this brief form that gives us more information about your family so that we may better serve your child.

Your name *

Last name

Email address *

Phone number

Phone type

What is your child's first and last name? *

Gender

Birthdate

Grade

Please tell us about your child's disability *

Does your child have any allergies to food and/or environment? *

How does your child communicate? *

Please check all that apply

Verbal

Non Verbal

Sign Language

Picture Exchange Communication System (PECS)

Assistive Technology (iPad, etc)

Other (please describe below)

If you chose "other" above, please describe why here:

Does your child have any special mobility requirements or equipment? *

Behavioral Tendencies *

Check all that apply

Meltdowns

Aversion to loud noises

Running away

Pushing

Biting

Hitting

Separation Anxiety

Difficulty following directions

Sensory processing sensitivity

Yelling

Aversion to touch

Self injury behaviors

Harm to others

Verbal aggression

Other (please describe below)

If you answered "other" above, please describe why here:

How do you handle the above behaviors? If no behaviors noted, please write "N/A" *

What are some of their likes and interests? (i.e. dinosaurs, music, coloring, etc.) *

What activities does your child NOT like to do? Is there anything we should avoid? *

Toileting Needs *

If your child is in grades K-5 and is not independent in this area, we will need to alert you during service if they need to use the restroom

Independent

Dependent

Other

If you answered "other" above, please let us know why.

If your child has seizures, what are the signs leading up to a seizure? How frequent are they typically, and what can we do if they occur? (If no seizure history, please write "N/A" *

Is there any other information you would like to share with us? *

SLO City Church
hello@slocity.church
805.316.1933

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