Family Intake Form for First B Friends

Your name *

Email address *

Phone number

Address

Participant Information

Parent/Guardian 2 Name

Parent/Guardian 2 Address (If different)

Parent/Guardian 2 Phone Number

Parent/Guardian 2 Email

Language spoken at home

Emergency Contacts

If you cannot be reached in case of an emergency list 2 contacts whom you give First Blairsville authorization to release your child.

Emergency Contact Name *

Contact Relationship *

Which service are you looking to attend? *

Sunday mornings 9am

Sunday mornings 10:45am

Wednesday evenings 6pm

Which setting would your family member best be discipled? *

In a typical setting for their age group with no supports

In a typical setting for their age group with a buddy

In a separate classroom with a trained teacher and other students with disabilities

A combination of the above choices that have been checked off

Buddy Preference - Gender

Male

Female

Buddy Preference - Type *

Peer Buddy

Adult

Need one on one assistance

Health and Medical Information

Participant's Diagnosis *

Severity *

Mild

Moderate

Profound

Additional Diagnoses

Please list any additional diagnoses, as well as the severity of each.

Briefly describe participant's disability *

Are there Emergency medications that need to be given to the medical team? *

Example: Epi pens, seizure medication, etc.

Yes

Directions *

Please check the best one that applies

Unable to follow directions

Follow simple 1 step directions

Follow 2 step directions

No difficulty following directions

Other

Communication - Speaking *

Please check all that apply

Predominately nonspeaking

Predominately speaking

Can speak clearly

Uses a communication device

Requires prompts/cues to initiate

Communication Tools

Please check all that apply

Sign Language

Picture Exchange System

Choice Board

AAC Device

Other

Seizures *

None

Controlled

Uncontrolled

Respiratory Problems *

None

Asthma

Other

Heart Problems *

Yes

Any additional medical concerns?

Caregiver Instructions

The most important things the caregiver needs to know about the participant.

They hear with: *

No assistance

a hearing aid

a Coclear implant

uses sign language

Able to read *

Yes

Able to write *

Yes

Nutrition *

List any foods that cannot be eaten due to allergies or dietary restrictions.

Eating ability *

By G Tube

By mouth independently

With required assistance or supervision while eating

They can use the bathroom: *

Please check any that apply

Independently

with supervision

with transfer assistance

by use of diapers/pull ups

If they have to use the bathroom: *

They will let you know verbally

by sign or gesture

you will need to prompt them following a schedule

Please share behavior tendencies we should be aware of (tantrums, biting, yelling, aggressive behavior, etc). *

A trigger point for these described behavioral tendencies can be: *

Please explain 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). *

They may require immediate medical attention when they exhibit this behavior: *

They love these things/activities: *

They don't like these things/activities: *

Sensory items or tools used at home/school that can help *

Their hobbies/talents are:

They're uncomfortable with or have an aversion to:

They like/don't like loud noises *

Don't like

They like or don't like large groups *

Don't like

They enjoy or don't enjoy music *

Enjoy

Don't enjoy

Please provide any other information you would like us to know.

Parent/Guardian Full Name *

Participant Information

Family Profile

Emergency Contacts

Program Preferences

Health and Medical Information

Caregiver Instructions

Behavior