Questionnaire Entry

Added: 6/10/2023

Which campus will your child be attending?

Parent's First Name

Parent's Last Name

Parent's Birth Date

Mobile Phone

Address

Child's First Name

Child's Last Name

Child's Birth Date

Child's Primary Diagnosis

Common Signs or Gestures
If your child is not verbal, please list common signs or gestures they would use to communicate their needs to us.

Food Allergies
List food allergies (separate by comma).

Behavioral Concerns
Please describe any behavioral concerns with your child such as hitting, biting, running from the room, or tantrums.

Response to Behavioral Problems
What is the best way to handle your child should a behavioral problem occur?

Things Child Enjoys
What are some things your child loves to do/play? Other interests?

Fears and Dislikes
Please list any things your child fears or dislikes.

Toilet Trained
Is your child toilet trained?

Bathroom Indications (Words)
What words does your child use to indicate that he/she needs to use the bathroom?

Bathroom Indications (Signs)
What signs or gestures does your child use to indicate he/she needs to use the bathroom?

Bathroom Indications (Other)
What other indications might suggest your child needs to use the bathroom?

Bathroom Assistance
Does your child need assistance using the bathroom? (Please explain. Leave blank if not applicable.)

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