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

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?

Tallowood Baptist Church