Special Needs Intake Form
Name of Individual with Special Needs
Date of Birth
MM slash DD slash YYYY
- Please Select =
Name of Person Completing this Form
Relationship to Individual
We would like to give your child/teen/adult the best experience possible in our Special Needs Ministry. If you are able, please provide some helpful information by answering the questions below so that we are aware of how to best serve your loved one.
Does the individual have any of the following needs: behavioral, cognitive, physical, or communicative, of which we should be aware?
Special Needs Details
Please provide any relevant details regarding needs.
Does the individual have any allergies?
Please list all allergies.
Is the individual prone to seizures?
Please provide any relevant details regarding seizures.
Please tell us about the individual’s likes and dislikes.
If toileting issues arise, the parent/caretaker will be texted.
This field is for validation purposes and should be left unchanged.