Special Needs Intake Form
Kids with special needs include any child with a physical, cognitive, medical, or hidden disability, those with chronic or life-threatening illnesses or those who are medically fragile.

Fill out 1 form PER CHILD. Multiple forms will be needed for multiple children. Please fill out as you feel comfortable so we can best serve you and your child.
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Child's Name *
Child's Birthdate *
Parent's Name *
Parent's Email
Parent's Phone Number
Briefly describe your child's disability (include diagnosis if applicable) *
Does your child have any allergies? If yes, please explain. *
Does your child experience seizures? If yes, please explain and include action plan. *
Briefly describe your child's interests/activities *
Briefly describe any sensory sensitivities your child might experience (e.g. light, sound, touch) *
Behaviors (Please check all that apply) *
Required
Please share any behaviors we should be aware of (i.e. aggressive behavior, tantrum, wandering, behavior triggers) and how would you like us to manage these behaviors? *
My child can communicate their wants/needs with others using: *
Required
My child can understand what others say: *
Is your child independent with toileting? If no, please explain and include action plan. *
Anything else we should know?
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