Childcare questionaire | autismone.org

Parent's Name(s):

Cell Phone Numbers:

Email Address:

Child's Name:

Child’s D.O.B.:

Diagnosis:

(Please note if the child is an NT sibling)

Allergies, (environmental and/or food):

Behaviors we should be aware of (that may affect staff or other children: biting, hitting etc):

Is your child verbal?:

Yes

No

If not, what manner of communication is used?:

Does your child nap regularly?:

Yes

No

If so, what time of day?:

Is your child potty trained?:

Yes

No

Please describe the best way to calm your child when he/she is upset, overwhelmed, over stimulated or angry?:

Are there any particular sounds, activities or environmental triggers that distress your child?:

Please list you child’s most preferred activities, toys, games, books etc.:

Is your child a sensory seeker? Please describe their sensory seeking habits and what we can do to accommodate.:

Finally, please list/describe any other pertinent information we should know that will help us provide the most successful experience for your child while in our care.: