Special Needs Intake Form

Let us know how we can provode a safe and loving environment for your child through buddy ministry. The information here will be shared only with those who need to know to serve your child. Feel free to use the parts of the form that are relevant to you and skip the rest.

Your name *

Email address *

Phone number

What is your child's name? *

What is your child's birthday? *

What are your child's past church programming experiences?

What are your child's strengths and interests?

Do you see any social or emotional challenges affecting your child? If so, tell us about it.

Does your child have any allergies, medical concerns, or physical limitations? If so, tell us about it.

How does your child communicate (verbal, nonverbal, signs, AAC, etc)?

Does your child demonstrate behavioral reactions such as hitting, running, throwing, etc? If, what triggers this behavior?

What helps to de-escalate any emotional / behavioral reactions?

What positive reinforcements do you recommend for your child?

Is there anything else you'd like someone caring for your child to know?

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