SPECIAL NEEDS

Thank you for taking the time to fill out our intake form. Your answers will help us determine the most appropriate placement whether is a mainstream environment with support or a unique space designed just for them.

The vision of the Special Needs Ministry is to come alongside families of individuals with special needs, showing and teaching them the love of Jesus in meaningful ways, and striving to remove barriers that keep them from participating in the Body of Christ.

    Campus Attending (required):
    Parent(s) Name (required):
    Cell (required):
    Child/Loved One’s Name (required):
    Goes by:
    Birth Date (required):
    Age Chronologicall (required):
    Age Developmentally (required):
    Special Needs and/or Medical Diagnosis (e.g. AU, DS, ED, RAD, Bipolar, DSI):
    I would describe my loved one as being/having (check all that apply):
    If Other please describe:
    My loved one responds best to - Check all that apply (required):
    My loved one’s normal disposition is (Check all that apply):
    My loved one’s favorite toy or activity is:
    My loved one really doesn’t like to:
    My loved one likes (check all that apply):
    If Other - please describe:
    Behavior Challenges(Check all that apply):
    If Other - please describe:
    When my loved one is unhappy, the following things might calm him/her down:
    Is your loved one hearing impaired:
    Method of Communication (check all that apply):
    If Other - please describe:

    Social Behavior

    Does your loved one have any socially inappropriate behaviors for us to be aware of? (i.e. self-arousal, aggressive, cursing etc). If so, please describe words/hand signals, (or other methods) you use to redirect:
    Restroom Needs (Please bring necessary supplies):
    How does your loved one communicate his/her need to go to the restroom?
    Describe your loved one’s mobility (i.e. wheelchair, needs special support, crawls, sits alone, stands alone, walks independently, etc):
    List any medical issues/related info(i.e. seizures/pre-indicators, tubes, buttons, medication changes, allergies, etc):
    Any special feeding issues/needs: (i.e. feeding tubes, no solid foods, etc.)
    Anything else you’d like us to know about your precious loved one/ your hopes & desires for their time with us, etc: