Family Ministry Care Plan

Describe your child's communication (select all that appply)

Typical

Non-Verbal

Echolalic

Sign Language

Difficult to Understand

Other

What is your child's developmental age?

What age group does your child best associate with?

List any significant medical or psychological diagnoses

Please explain any medical needs and/or medicine your child will require while in our care.

Does your child have any allergies that we need to know about?

My child uses an Epi-Pen

Yes

What activities, toys, and reinforcements does your child really enjoy and respond well to?

What activities, toys and reinforcements does your child dislike and/or respond poorly to?

Are there any concerns or challenges with eating/toileting? (please note if your child is not toilet trained.)

Does your child struggles with transitions? (Ex. moving from one classroom or activity to another) if so, what does your child respond well to?

Runs/Wanders

None 1 2 3 4 5

Refuses Supervision

None 1 2 3 4 5

Verbally Abusive

None 1 2 3 4 5

Sexually Inappropriate

None 1 2 3 4 5

Aggressive (bites, hits, etc)

None 1 2 3 4 5

Spits

None 1 2 3 4 5

Climbs

None 1 2 3 4 5

Other behavioral difficulties

How do you comfort your child when he/she is upset? What verbal/non-verbal cues work for calming your child?

How do you handle your child's misbehavior? How does he/she react?

Is there anything else we need to know about your child to give them the best experience?

Work Entry