Hand in Hand Questionnaire

Your name *

Email address *

Child's First and Last Name *

Parent's First and Last Names

Parent's Phone Number

Caregiver's First and Last Name (If someone other than parents are bringing the child to church.)

Caregiver's Phone Number

Introduce Us to Your Child! *

Go ahead and brag! Tell us about your child’s strengths, interests, favorite things or anything else that is really amazing about your child?

My child has the following diagnosis, medical condition or learning difference: *

My child has allergies/food sensitivities (choose one). *

Yes

My child has a special diet and should avoid:

My child is prone to seizures (choose one). *

Yes

Other

My child’s behavior may indicate a medical problem requiring immediate attention when:

What are your child's toileting needs (choose one)? *

Independent

With Assistance

Wears Diapers

Other

My child’s main mode of functional communication is:

My child may be trying to communicate their need for (describe)________ when he/she exhibits the following behavior: ________.

My child has a 504/Individualized Education Plan (choose one). *

Yes

Other

My child currently receives therapies and special instruction in:

A trigger-point for a potential meltdown is when:

When/if my child experiences a melt-down he/she calms when we:

My child enjoys music (choose one). *

Yes

Other

My child enjoys large group gathering time (choose one). *

Large group gathering time occurs during Kidz Church in the gym where children in all classes (1st through 5th grad) come together for worship songs, announcements, games, and offering time.

Yes

Other

My child seems most relaxed in settings (choose one): *

Alone

With a few children

Among many children

Other

My child enjoys arts and crafts (choose one). *

Yes

Other

My child is really picky about:

My child is uncomfortable with or has an aversion to:

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Classroom situations/behaviors you wish to be contacted about:

Do you prefer to be contacted about behavior/situation (choose one): *

Immediately

Discuss after church

Be contacted by phone during the week to discuss

Other

Please describe your child's understanding of and relationship with God.

Goals for your child at church:

Ideas/suggestions for Hand in Hand Ministry to better serve your family:

Is there anything else we should know?

Thank you! It is our pleasure to serve your child and family.

You will be contacted by email within a few days from filling out this form to further discuss care for your child. Your child will be placed on a waiting list to join Hand in Hand.

Medical Overview

Communication

Developmental

Behavioral

Sensory

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Thank you! It is our pleasure to serve your child and family.