Foothills Church Disability Ministry Intake Form

To help us best support your child, we ask that you complete a short intake form. This allows us to understand each child's unique needs, strengths, and preferences so we can provide a safe, welcoming, and personalized experience. Our goal is to partner with families in creating an environment where every participant can thrive and grow in their faith.

Child's Name(and nickname if applicable)

Child's Date of Birth

Child's Primary Diagnosis

Other Relevant Diagnoses/Suspected Diagnoses

Your name and phone number

Relationship to child

Email address

Personal Needs

Vision (Check all that apply)

Please select all that apply.

Typical Impaired Blind Other

Hearing (Check all that apply)

Please select all that apply.

Typical Impaired Deaf Hearing Aids Other

Mobility Skills (Check all that apply)

Please select all that apply.

Walks Uses a walker Uses crutches Uses braces Uses a wheelchair Other

Communication (Check all that apply)

Please select all that apply.

Verbal (words, phrases, etc..) Verbal, but not always with words or phrases Sign Language Uses device for communication Other

Toileting Status (Check all that apply)

Please select all that apply.

Toilets independently Potty trained, but may need assistance Potty trained, but wears pull-ups Frequent accidents Wears a diaper Other (if different, please be specific in the space below)

Specific toileting instructions (if needed)

Behavioral Needs

Sensory Needs

Trauma Background (check all that apply)

Please select all that apply.

Adopted Foster Care Divorce Death in family No identified trauma

List ANY and ALL allergies/food sensitivities (May list food aversions)

EPI Pen

Please select one option.

Yes No

Prone to seizures

Please select one option.

Yes No

Other medical concerns?

Foothills Church Disability Ministry Intake Form

Description

Please Fix the Following