2023-2024 Background Information, Wayfinders Special Needs Services
Before meeting with your family, please share a little more information about your child to help guide our conversation. Please answer as honestly as possible, so that together we can determine whether Wayfinders is a good match for your child.  Thank you!
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E-mailadres *
Child Information
Child's First Name *
Child's Last Name *
Age *
Gender *
Date of Birth *
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School *
Classroom Setting *
Grade *
Child's Diagnosis *
IEP/504/Other (if yes, please send a copy. If "other" please describe the document) *
Parent/Guardian Information
Parent/Guardian 1 Name *
Parent/Guardian 1 Relationship *
Parent/Guardian 1 Home Phone *
Parent/Guardian 1 Cell Phone *
Parent/Guardian 1 Email *
Parent/Guardian 2 Name
Parent/Guardian 2 Relationship
Parent/Guardian 2 Home Phone
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Email
Strengths and Interests
Please describe your child’s strengths *
What are your child’s hobbies and areas of interest? *
Health/Medical History and Information
Does your child have issues with hearing or vision? *
Please describe the hearing of vision issues, if any
Does your child regularly use any assistive devices (e.g. for communication, writing, mobility, etc.)? *
Sensory Sensitivities
Does your child exhibit any sensory issues/sensitivities? *
If yes, please select all that apply
Please explain how this might impact your child
Does your child have any activity restrictions? *
If Yes, please explain
Please list any other current health conditions that your child is experiencing but that have not been mentioned above (e.g., tics, anemia, diabetes, seizure disorder, etc.)? *
Please list all medications and vitamins that your child is currently taking and the purpose of the medication/vitamin/supplement. *
Social Functioning
How does your child tend to do socially – does he/she/they prefer to participate and be with other children, to be more of an observer, or to engage in more solitary activities? *
Does your child require encouragement and support to join in group activities? *
Please describe your child’s strengths and challenges during social interactions. *
Emotional and Behavioral Information
What are triggers or situations that your child finds challenging? *
 How does your child show that they are feeling frustrated, upset, anxious, or overwhelmed? What are the signs or behaviors? *
What have you found to be most effective to help your child manage those situations in which they become frustrated, upset, anxious, hyperactive, or overwhelmed? *
What specific activities help to soothe and calm your child? *
What is the best way to redirect your child, if necessary? *
What is the best way to help your child transition from one activity to the next? *
Does your child exhibit any repetitive behaviors? *
If yes, please indicate how the behaviors are addressed at home and school.
Does your child have a behavior management plan at home and/or at school? *
If yes, please indicate the behaviors that are addressed by the plan.
Does your child have any history of the behaviors listed below? If yes, please check all that apply: *
Verplicht
If you checked any of the above behaviors, please explain the circumstances and frequency of these behaviors.
Is your child neurodivergent?  *
Please describe.
Have there been any recent changes or stressors in your child's life that would be helpful for us to know about (e.g. new baby, move to new home, divorce, death, change of schools, family illness, etc.)?   *
If yes, how has your child reacted to those changes?
At Wayfinders, we spend the majority of our time outdoors, in the natural elements.  Do you foresee your child having any issues with any of the following natural elements? Check all that apply. *
Verplicht
Please explain how this might impact your child.
Daily Life Skills
Does your child have difficulty and require support with any of the activities below? If yes, please check all that apply.
 If you answered yes above please explain.
Additional Information
Is there anything that we have not yet covered that you think would be important for us to know?
Please list two professionals and provide their contact information who work with your child (e.g. teacher, therapist):
Please check the box below so that we can reach out to these professionals
Parent/Guardian Signature
Today's Date
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