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Special Needs Intake Form
Your name
*
Last name
Email address
*
Relationship to disabled:
*
Name of child with disability:
*
Child's DOB:
*
Child's Developmental Age:
*
Child's Diagnosis/es:
*
Behavioral Concerns:
*
Potential Triggers:
*
Sensory Needs/Aversions:
*
Reinforcers:
*
Eating Needs:
*
Restroom Needs:
*
Allergies:
Medical Needs/Concerns:
*
Situations you would like to be notified of via text:
*
Other concerns/things we need to know:
*
What service does your family typically attend on Sundays?
*
9:00am
11:00am
Would you like to be added to a GroupMe with other parents of children with Special Needs at Eastside to help build deeper community?
*
Yes
No
How can we specifically be praying for you and your family?
*
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