Special Needs
Intake Form

Child's Name

Child's Date of Birth

Guardian's Name

Phone Number

My child has the following learning difference, diagnosis, or medical condition:

My child has the following area(s) of interest:

My child needs assistance with (ex: using restroom, reading, writing):

My child is uncomfortable with (ex: loud noises, bright lights, physical touch):

My child may become frustrated, or a behavioral problem may occur when:

When/if my child experiences frustration, he/she calms when:

My child does or does not enjoy music:

Is there anything else you would like us to know about your child?

Our family has grown through one of the following: Adoption, Foster Care, Safe Families.

Your Signature

I have read this intake form and verify that the information is true.

I want to subscribe to the newsletter.

Thanks for submitting!