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Buddy Support Intake Form Blaine
Thank you for taking the time to fill out this questionnaire so we can best learn how to serve you and your child. We are so excited to have you here!
Your name
*
Last name
Email address
*
Phone number
*
Phone type
Mobile
Home
Work
Other
Preferred method of contact:
*
Phone
Email
Text
Relationship to Child
*
Is this your first time attending Renovation Church?
*
Yes
No
We plan to attend:
*
Every week
2x per month
Occasionally
Other
Child Information
Child's Name
*
Birthdate
*
Date
What is your child's primary diagnosis or area of concern? Include a brief description.
*
Does your child receive additional support at school?
*
Does your child take any medications we should be aware of?
*
Yes
No
What type of assistance would be most beneficial to your child?
*
Integration buddy (integrated into typical classroom with 1:1 support)
Buddy base (Sensory friendly classroom for kids who would benefit from a separate enviornment)
Personal Care Attendant (Provided by the parent. Background check required.)
No additional support needed, just want you to be aware.
My child's strengths include:
*
My child responds to separation from parents/guardians by:
*
My child is best comforted or calmed by:
*
My child likes/is motivated by:
*
My child dislikes/is triggered by:
*
Some signs my child is upset or in pain include:
*
Toileting skills
*
Fully independent
Mostly independent but needs assistance
Not potty trained
Other
Vision
*
No concerns
Impaired
Blind
Speech
*
No concerns
Phrases
Sentences
Babbles
Gestures
Sign Language
Communication device (AAC)
Other (Please describe)
Other
Hearing
*
No concerns
Impaired
Deaf
Uses hearing aid
Can understand what others say:
*
All of the time
Most of the time
Some of the time
None of the time
What are some of the hopes you have for your child while they are here at church?
*
Any additional comments or things we should be aware of:
Thanks!
Thank you for taking the time to fill out this questionnaire so we can best learn how to serve you and your child. We are so excited to have you here! If you have any questions, please contact our Buddy Team Coordinator, Megan Hanson at megan@renovationchurch.org.
Submit
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