Plan of Care Form

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This intake form is designed to help us create a “plan of care” for coming alongside your child affected by disability. We appreciate you taking the time to fill out this form and equip us with needed information to care as best we can for your child.

General Information

Your Name(Required)

First Last

Are you a parent or legal guardian of the child for which you are filling out this form?(Required)

Parent

Guardian

Your Address(Required)

Street Address Address Line 2 City ZIP Code

Do you have any past experience(s) attending a local church with your loved one?

How Can We Reach You?

At the completion of this form, our family coordinator will touch base in the near future. How should they contact you?

Preferred Method of Contact(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Plan of Care

Any information you share here is confidential and only shared on a need-to-know basis. The more details, the better as it helps us prepare as best we can for coming alongside your child with special needs.

What is your child's name?(Required)

First Last

Date of Birth(Required)

In a few sentences, introduce us to your child:(Required)

What is wonderful about your child?(Required)

What goal(s) do you have for your child's participation in the life and programming of Sunset Bible Church?(Required)

Communication

How does your child communicate?(Required)

Verbally/easily understood

Uses some words

Limited verbal communication

Uses gestures

Uses signs

Uses a device

Any additional communication comments

Social/Behavior

What is reinforcing or motivating to your child?(Required)

What are some of your child's favorite things? (toys, activities, songs, tv shows, places, etc.)(Required)

What does it look like when your child is frustrated?(Required)

Does your child ever display aggressive behaviors?(Required)

Yes

Please describe any aggressive behaviors and where the aggression is directed (towards self/others/etc.)(Required)

Are there any known triggers for behaviors?(Required)

What ways do you warn your child for transitions?(Required)

Please explain in detail the behavior management plan being used at home and/or school to modify inappropriate or undesirable behavior that may be exhibited. Our goal is to maintain consistency in the implementation of this plan as best we can in our context.(Required)

Any additional social/behavior comments

Motor

How does your child get around?(Required)

Ambulatory

Walker

Wheelchair

Wheelchair use(Required)

Independent

Needs Assistance

Does your child tend to wander or run away? Please describe.(Required)

Any additional motor comments

Sensory

Does your child demonstrate sensory differences?(Required)

Is your child bothered by(Required)

Lights

Sounds

Touch

Smells

None of the Above

Does your child seek any of the following sensory inputs(Required)

Touch

Movement

Auditory

Visual

Oral

Smells

None of the Above

Please describe any sensory inputs selected(Required)

Any additional sensory comments

Medical

Does your child have an medical needs?(Required)

Are there dietary restrictions and/or allergies?(Required)

Does your child take medication that needs to be administered?(Required)

Any additional medical comments

Miscellaneous

Are there any safety concerns?

Are there specific things used to comfort?

Are there specific things to avoid?

Are there any relevant past experiences that may impact your child's experience in a church classroom setting?

How can we pray for your family?

Plan of Care – Special Needs Intake Form