Special Needs Intake Form

Child's First Name*

Child's Last Name*

Child's Date of Birth*

Grade Level*

Gender*

Female
Male
Prefer not to answer

Parent's Name*

Address

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone

Cell Phone

Work Phone

How did you hear about the KOL program?*

Direct mail/email
Live/work nearby
Fair event
Word of mouth
Print ad
Website
Social media
Other

What class(es) are you interested in?*

SO Magic
Super Soccer Stars
Play Capoeira
Music Makers
ARTS Rx – Creative Movement
ARTS Rx – Arts
SO Yummy (Cooking)

Home & School

Number of Siblings*

Have there been any recent changes or stressors in your child's life that would be helpful for us to know about?*

Examples: new baby, move to new home, divorce, death, change of schools, family illness, etc.

What is the name of the school your child attends?*

How long have they attended the school they are currently in?*

Classroom Setting*

Mainstream
Inclusion
Self Contained
Aide
Other

Please describe your child’s classroom setting*

Typical or specialized classroom, student to staff ratio, level of support, etc.

Does your child have an IEP?

If yes, and you would be willing to provide us with a copy, please upload it here.

Max. file size: 100 MB.

List all services your child is receiving, both from the school system and privately.*

Examples: aides, resource room, speech-language, counseling, OT, social skills group, psychiatry, etc.

Child's Diagnosis

Does your child have any specific sensory sensitivities?*

Does your child have any allergies to specific materials, foods, or any other relevant medical history?*

Does your child have any behavioral or emotional challenges?*

Does your child have a behavior management plan at home or at school?*

Yes
No

Please indicate how the behaviors are addressed at home and school

Does your child have any specific triggers?*

How does your child show that they are feeling frustrated, upset, anxious, or overwhelmed? What are the signs or behaviors?*

What have you found to be most effective to help your child manage those situations in which they become frustrated, upset, anxious, hyperactive, or overwhelmed?*

What is the best way to redirect your child, if necessary?*

What is the best way to help your child transition from one activity to the next?*

Please describe your child’s strengths*

How does your child tend to do socially?*

Does your child prefer to participate and be with other children, to be more of an observer, or to engage in more solitary activities?

Does your child have any history of the behaviors listed below?*

Verbal aggression
Physical aggression
Self-injurious behaviors
Running away or “bolting”
Wandering away from the group
Being suspended from school
None of the above

If you checked any of the above behaviors, please explain the circumstances and frequency of these behaviors.

What are your child’s hobbies and areas of interest?*

What other activities does your child participate in outside of school?

Is there anything that we have not yet covered that you think would be important for us to know? Any objectives you have for your child(ren) during their participation in the KOL program?*

Post Custom Field

Login to 14th Street Y

Special Needs Intake Form

Special Needs Intake Form

Home & School

Child's Diagnosis