RCK Neurodivergent Intake Survey

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Thank you so much for taking the time to help us learn more about your child(ren) and family.

Our Vision: One of our goals in RCK is to work towards providing a ministry that gives all kids access to grow in their faith. In addition, we want to enable our royal city kids to deepen their relationship, understanding and experience with God and the body of Christ. We intend to do this by developing an inclusive, supportive and intentional environment for all RCK families.

We would love to learn how we can best support your family by providing us with relevant information regarding the needs of your child and/or family. With that being said, please understand that we respect your family's right to privacy. Any information shared on this form is voluntary and will only be used, reviewed and shared on a need to know basis to best serve your child during their time in RCK.

Finally, we understand that this is important work and want to develop in this area with grace, excellence and wisdom. Therefore, this survey is not guaranteeing any particular service or accommodation at this time. However, the RCK staff will use the information from this survey to better understand our current ministry needs and work towards developing our programs to better serve our neurodivergent kiddos and families. Further communication will be shared as developments are implemented within RCK.

If you have any further questions or concerns do not hesitate to reach out to our RCK Director at kids@sanctuarycolumbus.com

Email *

Please list the name of the child you are filling this form out for *

Please list your child's age *

Please provide parent/Guardian Name, Number and Email address *

Please provide information regarding any diagnoses, medical conditions or learning conditions that you would like RCK volunteers and staff to know while serving your family: *

Please describe what accommodations or modifications your child will need to participate in RCK:
*

Pre/Late Check-in

Special Diet and/or food restrictions

Frequent Movement Breaks

Fidgets/Regulatory items

Calming Space/Room

Large Print (Visual)

Braille

Noise cancelling headphones

Required

Please describe what accommodations or modifications your child will benefit from (can make their experience more inclusive and enjoyable) while participating in RCK:
*

Please check the environment you believe your child would be most successful in (can check more than one):
*

Regular worship experience

Regular worship experience with accommodations/modifications (including access to a calming space)

Regular worship experience with an RCK buddy (one-on-one support)

Small group worship experience

Required

Please describe your family's goals for your child's experience while attending RCK:
*

Please describe your child's interests (what motivates, excites or grounds them? This can be activities, topics, rewards, behavior charts, coping skills, etc.)
*

Please describe things your child is able to do independently (bathroom, mobility, communication, regulation, etc.):
*

Please describe things your child will need assistance with (bathroom, mobility, communication, regulation, etc.):
*

Please list any sensitivities (noise, light, textures, etc), aversions, triggers or frustrations (if any) that your child may experience:
*

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