Thrive
Cornerstone Special Needs Ministry
Family
Child's Name
First Name
Last Name
Child's Age
Parent's Name:
Sibling's Names
Parent's Cell Number
-
Area Code
Phone Number
My Child has the following diagnosis, medical condition or learning difference:
My Child Needs one on one attention:
Yes
No
Any food Allergies or food sensitivities?
Is your child prone to seizures?
Yes
No
Medical
A trigger-point of resistance, frustration or behavioral problem may emerge for my child when:
My child is uncomfortable with or has an aversion to:
When/if my child experiences a period of frustration, he/she calms when we:
My child enjoys music:
Yes
No
Your child seems most relaxed in which setting:
Alone
With a few children
Among many Children
My child's behavior may indicated a medical problem requiring immediate attention when:
Is your child non-verbal?
Verbal
Non-Verbal
Verbal
Non-Verbal
My Child's main mode of functional communication is:
My child can do these things independently:
My child's interests are:
My Child is very picky about:
My child may be trying to communicate their need for _______________ when he/she exhibits the following behavior:
My child needs assistance with___________:
Other information or comments:
Attention: Keep your phone with you at all times:
Submit
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