Where can you be located while your child is with us?* • Attending a Bible study? Please provide class time and room number.
• Please give us a general idea of where you sit during services should we need to find you.
What is your child's specific diagnosis?* (please provide as much information as you can)
Please list any additional medical conditions: (please provide as much information as you can)
Please provide additional details:* It looks like you checked "other" for one of the questions in the Social Positive section. Please provide the corresponding details for all applicable questions.
Please provide additional details:* It looks like you checked "other" for one of the questions in the Social Negative section. Please provide the corresponding details for all applicable questions.
Please provide additional details:* It looks like you checked "other" for one of the questions in the Automatic Positive section. Please provide the corresponding details for all applicable questions.
Please provide additional details:* It looks like you checked "other" for one of the questions in the Automatic Negative section. Please provide the corresponding details for all applicable questions.
Sensory Needs* Please provide as much detail as possible:
Any other dietary restrictions? Does your child have dietary restrictions? Can your child feed his/herself independently? Does your child use utensils? Please describe below.
Do they require assistance when using the bathroom? Describe the level of support needed in the restroom, if any.