Special Needs Ministry Intake Form - Thomas Road Baptist Church

Mother's Name

Father's Name

Guardian's Name

Child/Teen Name *

Birthdate *

Age *

Phone number *

Address *

Gender *

In case of emergency, notify *

Name, Relationship, and Phone #

Primary Disability *

Secondary Disability

Allergies

Medications we should be aware of

Special Diet (Please Specify)

Primary Physician *

Name, Phone #

Bowel & Bladder *

Independent

Partial Assist

Total Assist

Diaper use

Eating *

Independent

Partial Assist

Total Assist

Uses Adaptive Device

Drinking *

Independent

Partial Assist

Total Assist

Uses straw or other adaptive equipment

Sight/Vision *

Normal

Partial or Impaired

Legally blind-no vision

Hearing *

Normal

Hearing impaired

Deaf

Ambulation *

Normal

With Difficulty

With Aid

Wheelchair: Self

Wheelchair: Needs Assist

Orientation/ Attention/ Concentration *

Normal

Somewhat Distracted

Easily Distracted

Difficulty in large group setting

Other

Oral Expressive Language *

Very Articulate

Average Articulate

Poor Articulate

Non-verbal

Uses Sign Language to communicate

Receptive Language *

Can process/act immediately on directions

Needs time to process/ act on directions

Needs cues/ prompts/second set of directions

Social Interest *

Seeks social contact/ interactions

Does not initiate but does not avoid either

Does not process directions

Avoids social contact/ situations

General Participation *

Self-initiating

Complies w/ activities initiated by others

Responds to direct instructions

Does not participate

Cooperation *

Understands/ engages in cooperative behavior

Cooperation with prompting or reinforcement

Does not engage in cooperative behavior

Competition *

Understands/ engages in competitive behavior

Aggressive in competitive behavior

Does not engage in competitive behavior

Emotional Expression *

Age appropriate behavior

Loses emotional/ physical control but can be assisted by adult

Loses emotional/physical control w/ adult guidance

Authority/ Leadership *

Responds appropriately

Resists authority

Overly passive w/ authority

Frustration *

High toleration

Average tolerance

Frequently frustrated

Please indicate best types of cues/ prompts to use if needed:

Any other helpful information about your child:

Please indicate any adaptive equipment/ device used:

Section 2: TRBC NextGen Release Form *

Please click Yes to complete release form

Yes