North Monroe Baptist Church

Open Arms

Special Needs Ministry Intake

Thank you for taking the time to fill out our intake form. Your answers will help us determine the most appropriate placement whether it is a mainstream environment with support, or a unique space designed just for them. This will help us best minister and serve your loved one.

Parent's name

First Name

Last Name

Cell Number

Child/Loved One's name

Goes by

Birthdate

Chronological age

Developmental age

Special needs and/or medical diagnosis (e.g. AU, DS, ED, RAD, Bipolar, DSI)

I would describe my loved one as being/having: (check all that apply)

Medically fragile / mobility-impaired

Active and mobile

Seizure disorders

Other

If checked, please give a brief description

My loved one responds best to (check all that apply)

Males

Females

Someone their own age (male or female)

My loved one's favorite toy or activity is

My loved one really doesn't like to

If other, please describe

When my loved one is unhappy, the following things might calm him/her down

Is your loved one hearing impaired?

Restroom needs (please bring necessary supplies)

Wears diapers

Needs help

Independent

How does your loved one communicate his/her need to go to the restroom?

Verbally

Sign/hand signal

Hiding

Other

If other, please tell us more

Describe your loved one’s mobility (i.e. wheelchair, needs special support, crawls, sits alone, stands alone, walks independently, etc)

List any medical issues/related info (i.e. seizures/pre-indicators, tubes, buttons, medication changes, allergies, etc)

Any special feeding issues/needs: (i.e. feeding tubes, no solid foods, etc.)

Anything else you’d like us to know about your precious loved one/ your hopes & desires for their time with us, etc:

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Open Arms

Special Needs Ministry Intake

Parent's name

Monroe

Bastrop

Contact Info

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