VIP Intake Form - Zeal Church

Phone number

Household members

Diagnosis: *

Physical Needs

Please check as many boxes as apply, and provide any additional information in space at the end
of this section.

Vision: *

Typical

Impaired

Blind

Other

Hearing: *

Typical

Impaired

Deaf

Hearing Aid

Other

Motor Function: *

Head Control

Rolls Over

Sits

Crawls

Cruises

Walks

Walker

Crutches

Braces

Wheelchair

Other

Toileting Skills: *

Toilets independently

Needs assistance

Wears a diaper

Being potty trained

Other

Eating Habits: *

No restrictions

Nothing by mouth

Soft foods only

Bottle

Other

Feeding instructions or tips:

List any food allergies:

Does your child have a history of seizures? If so, please explain.

Communication: *

Verbal

Limited Verbal

Nonverbal (no communication device)

Nonverbal (uses a communication device)

Sign Language

Other

Can understand what others say: *

All the time

Most of the time

Some of the time

My child responds to separation from parents by: *

My child is best comforted by: *

My child lets someone know what they need by: *

Activities:

Activities my child likes: *

My child needs encouragement to: *

My child does not enjoy: *

Please do not ask my child to: *

My child learns best when: *

My child participates more when: *

Behavior: *

Please check all that apply

Outgoing

Shy

Plays in groups

Adapts to new situations well

Adapts to new situations with difficulty

Responds to correction well

Responds to correction with difficulty

Is sometimes destructive

Sometimes threatens others

Sometimes hits, bites, or hurts self/others

Sometimes attempts to run away

Hyperactive or ADHD

Oppositional defiant disorder (ODD)

Gets overwhelmed in large crowds

Other

Other Things to Know About My Child

Please provide any additional information that may be helpful for team members to best serve
your child.