Tallowood Baptist Church | Houston, Texas
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Informational Questionnaire
We request this information in order to provide a safe place for your child/adult and to offer the best worship environment for all. We respect your right to privacy; be assured that we only share information from this form on an "as needed" basis to those caring for your loved one.
Note: Your child or adult's participation in the Special Needs Ministry gives Tallowood Baptist Church permission to use photos for church purposes. Children and adults in photos will not be identified.
Form completed by:
Today's Date:
General Information
Attendee's Name
First
Last
Birthday
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Mother's Information
Mother's Name
Home Address
Email
Cell Phone
Home Phone
Work Phone
Father's Information
Father's Name
Home Address
Email
Cell Phone
Home Phone
Work Phone
Please provide an additional name with contact information, in the event we are unable to reach you. List name, phone and relationship.
Are there custody concerns we should be aware of? (If yes, please explain.)
What are your child's strengths? (Go ahead and brag here!)
Medical
Diagnosis
*
None
Yes
Please share helpful information with us if you answered yes:
*
Allergies
*
None
Yes
Please specify if you answered yes
*
Epi-Pen
*
No
Yes
Please share any medical concerns your child/adult may have. Include diagnosis. Be specific about allergies, seizures, G-tube, trach, medication, other special concerns.
Developmental age:
Does your child/adult need help eating or drinking? If so, explain.
Please advise regarding dietary restrictions:
Restroom
How does your child/adult use the toilet? (mark all that apply)
Independently
With supervision
Needs full assistance
Wears pull-ups
Wears diapers
How does your child/adult indicate the need to use the toilet?
Special instructions?
Communication
Mark all that apply
Verbal
Non-verbal
Limited speech
Gestures
Signs
Picture Communication Symbols
Communication board
Eye gaze
Assistive Technology (computer assisted communication)
Additional Information
Behavioral
Mark all that apply
Running away
Biting
Scratching
Temper tantrums
Aggression toward other children
Aggression toward adults
Triggers (provide examples)
Trigger examples:
Other behavioral concerns:
Recommendations for handling these behaviors:
Things your child/adult really does NOT like: (Mark all that apply)
Schedule change
Loud noises
Music
Other dislikes:
Friends & Family
Who are the friends and family members important to your child/adult - siblings, grandparents, aunts, uncles, etc? (We like to talk about people we love!)
Does your child/adult have any pets? (We like to talk about pets!)
Other
Things your child/adult really loves: (Mark all the apply)
Books
Music
People
Toys
Outside
Walks
Playing in the water
Technology
Movies/TV
Other likes:
When upset or frustrated, what is the best way to calm your child/adult?
What is your child/adult's favorite activity at home? (We like to talk about things we like!)
Is there anything else we should know that will help us minister more effectively to your child or your family?