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I Heart Church
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INTAKE FORM
Care Team Intake Form
Any area marked with an "*" is a requirement for submission of form.
Child's Name
*
Date of Birth (DOB) mm/dd/yy
*
Grade
*
What grade is your child in?
Contact Information
Primary Contact Name
*
Relationship to child
*
Phone
*
Email
*
Secondary Contact Name
Relationship to child
Phone
Email
Child's Information
Tell us about your child's strengths. (Don't be modest!)
Please list your child's interests. (Help us form relationships.)
Does your child have a favorite item or toy to carry?
Things/activities my child likes:
Things/activities my child dislikes:
Health or Medical Needs
*
Please tell us about any health or medical needs that would allow us to best support your child and keep them safe. Please list any diagnosis, medical condition, disability or learning differences here:
Behavioral Tendencies
Please check any of the behavioral tendencies that apply.
Shy
Tantrums
Stimming
Biting
Meltdowns
Other
If "Other" Please list (ex: Stimming tendencies or behaviors).
Calming Strategies
How do you handle behaviors?
A trigger point for potential meltdown is
My Child's behavior may indicate a problem requiring immediate medical attention when:
Communication Skills
Please check any of the communication skills that apply.
Nonverbal
Verbal
Communication Device
Other
Please list if "Other".
Does your child follow verbal directions?
Yes
No
Does your child require repetitions?
Yes
No
Does your child respond better to directions with gestures and pictures/visual schedule?
Yes
No
Care Information
Please check all that apply regarding care information.
Please list any specifics of items checked in the area provided below.
Special Diet
Allergies
Will Choke/Aspirate
Medical Issues
Will Run
G/Tube, Tracheotomy or Catheter
Will Hit/ Can be aggressive
Needs assistance with eating/drinking
Needs assistance in the restroom
Sensory Issues
Adaptive or mobility equipment (including hearing aids, glasses, walker, wheelchair, forearm crutches, etc.)
Other
Please list "Other".
Does your child enjoy music?
Yes
No
Would your child enjoy a large group worship experience?
Yes
No
Please provide any information that you think would be helpful for us to better serve/assist your child and their needs.
If you already have a caregiver sheet created for child, you can upload here.
Verification
Please enter any two digits
*
Example: 12
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please leave it blank
: