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If you think your child may benefit from being a student in our classes, please complete the following survey. All information will be kept strictly confidential.

Child's Name
Parent's Name
Child's Age
Parent Phone Number
Parent Email Address
Preferred Method of Contact Email Phone
Does your child walk independently? Yes No
Is your child sensitive to noise? Yes No

If YES, please describe
Is your child easily distracted? Yes No
Is your child easily comforted when upset? Yes No
Does your child have any phobias or dislikes? Yes No

If YES, please describe
Does your child have any aggressive or self-abusive tendencies? Yes No

If YES, please describe

Describe your child's communication abilities (verbal/nonverbal).
Does your child have any self-stimulatory behaviors? Yes No

If YES, please describe
Is your child on any medication? Yes No

If YES, please describe
Is your child involved in an ABA program/therapy? Yes No

How does you child interact with his/her peers and with other adults?
Does your child have any sensory defensive behaviors (sensitivity to certain clothing textures, tags, etc? Yes No

If YES, please describe
Does your child have any visual or auditory impairment? Yes No

If YES, please describe
Has your child been involved in group activities before? Yes No

If YES, please describe
Does your child have seizures? Yes No

If YES, please describe

Briefly describe any unique qualities that your child has.

What are your expectations for your child in this program?