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Unlimited: Parent Questionnaire
Unlimited: Parent Questionnaire
Jason Chelf
2020-12-30T13:18:01-05:00
Child's Name
*
First
Last
Date of birth
*
MM slash DD slash YYYY
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
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
Other...
How does your child show that he/she is upset?
*
Crying
Hiding
Pulling hair
Running away
Pinching
Hitting
Kicking
Scratching
Spitting
Yelling
Other
Other...
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:
Name
This field is for validation purposes and should be left unchanged.
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