Unlimited: Parent Questionnaire

Child's Name*

First Last

Date of birth*

Does your child attend school?*

Yes
No

School Information

Current grade:

Name of School

Does your child receive therapy?*

Yes
No

Check all that apply:

Speech Therapy
Physical Therapy
Occupational Therapy
Other

If other, please describe:

Personal Information

Strengths of your child:*

What does your child like to do?*

Blow Bubbles
Play Doh
Swing
Color / Crafts
Sing Songs
Read Books
Jump on Trampoline
Other

What toys does your child like to play with?*

My Child Likes:*

My Child Dislikes:*

Does your child enjoy music?*

Yes
No

What are some of his/her favorite songs?

My child can do these things independently:*

My child will need assistance with:*

What triggers frustration for your child?*

Is there anything that makes him/her uncomfortable?*

When your child is frustrated, how do you calm him/her?*

What behaviors might your child exhibit that you would want us to contact you during church service?*

Communication Information

How does your child communicate with you?*

Sign Language
Gestures (Pointing)
Nonverbal
Pictures (PECS)
Verbally
Communication Device
Other

How does your child show that he/she is upset?*

When he/she exhibits the following behavior:

He/she may be trying to communicate their need for:

Medical Information

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

Does your child have allergies?*

Yes
No

Please list allergies and severity:

Is your child prone to seizures?*

Yes
No

How severe are his/her seizures?

Please describe what his/her seizures look like:

Contact mom or dad if my child's seizure lasts more than:

(Number of minutes)

Call 911 if my child's seizure lasts more than

Any other relevant medical information we should know?

Family Information

Primary Contact*

First Last

Primary Contact Cell*

Primary Contact Email*

Additional contact information

Mom
Dad
Other

Check those you wish to add as additional contacts

Mom

First Last

Mother's Cell

Mother's Email

Dad

First Last

Father's Cell

Father's Email

Other

First Last

Other's Cell

Other's Email

Does your child have any siblings?*

Yes
No

Please list siblings names and ages:

Do you have any pets?*

Yes
No

Please list type and name of pets:

List any other relevant information:

Comments

This field is for validation purposes and should be left unchanged.