Westwood Baptist Church - WonderKids Intake Form

INFORMATION

Participant's First Name

Participant's Last Name

Participant's Home Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Participant's Birthdate

Participant's Gender

Male

Female

School Participant Attend (if applicable)

Parent/Guardian First and Last Name

Parent/Guardian Phone Number

Parent/Guardian Email

EMERGENCY CONTACT

If you cannot be reached in case of an emergency, please list 2 contacts that Westwood may communicate with.

1st Emergency Contact's Name, Phone Number, and Relationship to Participant

2nd Emergency Contact's Name, Phone Number, and Relationship to Participant

Participant's Preferences

Which setting would be the best for the participant to be discipled?

in a typical setting for their age group with a buddy

In a classroom with a teacher and other students with special needs.

A hybrid of the two above options

Te participant functions best when:

he/she is alone

he/she is with a few others

he/she is among many others

Pick-Up Preference:

For participants UNDER 13 years old, parent/guardian must pick them up from the WonderMade Sensory Room

For participants OVER 13, participant may leave at dismissal on their own and reunite with their family at their predetermined spot within the church building

For participants OVER 13, participant must be picked up by a parent/guardian from the WonderMade Sensory Room.

Please initial to confirm your pick-up preference:

What are some of the participant's favorite activities?

What makes the participant smile?

What are some of the participant's favorite snacks or treats?

Goals for the participant at church:

MEDICAL NEEDS

Medical Diagnosis (if applicable; type N/A if not applicable)

Please list any/all allergies, or type N/A

Are any of the allergies above life-threatening and require an Epi-Pen?

Yes

No

Please advise the location of Epi-Pen if applicable:

Are there emergency medications that the Special Needs Coordinator and team needs to be aware of?

If there are emergency medications that we need to be aware of, please explain:

RESPIRATORY CONCERNS

Does the participant have asthma?

Yes

No

If the participant has asthma, what might trigger an attack?

If the participant has asthma, do they use a rescue inhaler?

Yes

No

N/A

Please advise the location of rescue inhaler:

SEIZURE INFORMATION

Does the participant experience seizures?

None

Controlled

Uncontrolled

If the participant does experience seizures, is there emergency medication to administer?

Yes

No

N/A

Seizure Medication:

Date of Last Seizure:

What do these seizures typically look like?

What triggers the seizures?

How can we prevent a seizure or best response to one?

Any other health issues or concerns?

COMMUNICATION

What is the participant's primary mode of communication? (Check all that apply)

The participant is predominately nonverbal

The participant is predominately verbal

The participant can speak clearly

The participant uses a communication device

The participant uses sign language

Hearing:

The participant hears with no assistance

The participant uses hearing aids

The participant has cochlear implants

Additional information regarding the participants means of communication:

NUTRITION

The participant cannot eat the following foods due to allergies or dietary restrictions:

The participant eat: (select all that apply)

By G Tube

By mouth independently

With required assistance or supervision while eating

Eating Instructions

TOILETING

Our toileting policy here at Westwood for those who are not independent in the restroom is having 2 volunteers assisting the participant if necessary

The participant can use the bathroom: (select all that apply)

independently

with supervision

with transfer assistance

by use of diapers/pull-ups

If the participant needs to use the restroom:

he/she will let you know verbally

by sign or gesture

you will need to prompt him/her

Additional comments regarding toileting:

BEHAVIOR

The participant: (check all that apply)

follows 1-step instructions

follows 2-step instructions

has no difficulty following directions

is unable to follow directions

Is the participant able to write?

Yes

No

Is the participant able to read?

Yes

No

Please share behavior tendencies the WonderMade team should be aware of (tantrums, biting, yelling, aggressive behavior, etc.)

The participant is uncomfortable with or has an aversion to:

Trigger points for resistance, frustration, or behavioral challenges:

Please explain any behavior management plans being used at home/school to modify any inappropriate behavior that may be exhibited (our goal is to maintain consistency in the implementing of this plan and work with you in the process)

Is the participant prone to wandering off or running?

Yes

No

If the participant is prone to wandering off or running, are there any triggers?

OTHER INFORMATION

Is there any other information you would like to share with us that would help us best serve the participant and your family?

May the participant be photographed and images be used on Westwood's social media, website, or other outlets?

Yes

No

I understand that a Westwood WonderMade team member will contact me to schedule an intake meeting before the participants first visit to our WonderMade program.

Yes

WonderMade Kids Intake Form

INFORMATION

EMERGENCY CONTACT

Participant's Preferences

MEDICAL NEEDS

OTHER INFORMATION

Gathering Times

Contact Info

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