OCH Special Needs Profile Form

Your name *

Email address *

Address *

Child's Date of Birth and Grade *

Mother's Phone Number *

Father's Phone Number *

Does the child live with both parents? *

Are there any custodial arrangements that One Church Home needs to be aware of? Please explain. *

Please list the child's siblings and ages. *

Diagnosis:

We believe everyone is created in the image of God. A diagnosis does not define an individual but "Child of God" does. Knowing your child's diagnosis helps us serve your family better.

Please check any special needs that your child has been diagnosed with. *

ADD/ADHD

Autism Spectrum Disorder (ASD)

Cerebral Palsy

Down Syndrome

Emotional Disturbance

Epilepsy/Other Seizure Disorder

Learning Disability

Intellectual Disability

Speech/Language Delayed

Tourette Syndrome or other Tic Disorder

Traumatic Brain Disorder

Sensory Processing Disorder

Oppositional Defiant Disorder

Other

If other is checked, please list. *

Parent Description *

In your own words, describe your child. Please let us know what makes your child unique.

Medical Issues *

Please list any additional medical issues or special concerns.

Toileting/Special Care

Is your child toilet trained? *

How does your child communicate his/her toileting needs? *

Is your child independent with all toileting/self-care needs? If assistance is required, please describe the assistance he/she needs. *

Please note that parents or legal guardians will change all special needs individuals age 4 or older.

Does your child have any food allergies and/or preferred dietary restrictions? If so, please list. *

Is your child independent with feeding or require any special assistance? *

Is your child verbal or non-verbal? *

If non-verbal, do they communicate with ASL, gestures, or any assisted technology devices? *

Please list any negative behaviors exhibited at school and/or at home. *

Does your child have a behavior plan at home or school? Would you be willing to provide a copy to be kept in a confidential file at church? *

What are effective ways to reinforce positive behaviors? (Ex. praise, physical touch, small tokens/prize, quality time, etc.) *

What are effective ways to discourage negative behavior? (Ex. time out, ignoring behavior, withholding, behavior chart, etc.) *

OCH Special Needs Profile Form

Diagnosis:

Toileting/Special Care

Dietary/Feeding

Communication

Behavior