Other children in family (names and ages)
Please list any special need, disability, or diagnosis your child may have.
What are the fine and gross motor limitations for your child?
How does your child communicate?
Personal care needs (i.e. feeding, toileting) or any other specific needs requiring assistance?
Does your child have any dietary concerns? (allergies, etc.)
Behavioral Issues: Please include information about what situations trigger behavior, what are your strategies to manage the behavior, what does your child find comforting when he/she is upset?
What does your child like to do for fun or during free time?
Does your child play independently?
Other comments:
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