Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Verbal / Non-Verbal *

Predominately Non-Verbal

Predominately Verbal

Check all that apply… *

Speaks clearly

Requires prompts/cues to initiate

Vocalizations not always understood

Requires prompts to interact

Can express basic needs and wants by… *

Eye Contact

Gestures

Signs

Assistive Technology (picture boards, books, talkers)

Other

Check all that apply… *

Eats by mouth

Independently with set-up

Eats by G-Tube

Feeds self with prompts

Uses special utensils / cup

Requires supervision / physical assistance while eating

Check all that apply… *

Uses the toilet independently

Uses the toilet with supervision

Needs transfer assistance (explain below)

Follows schedule (explain below)

Wears diapers / pull ups

I feel my child would be most successful (check all that may apply)… *

Participating in a whole group setting without support (i.e. with a shepherd)

Participating in a whole group setting with support (i.e. with a shepherd)

Participating in a whole group and a small group with support

Participating in a small group

Participating in a supervised 1-on-1 setting

When it is necessary, my child may take a break from the group setting and go for a walk, find a quiet and calm place or participate in a small group activity… *

Yes

No