Parent (1) Name
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First Name
Last Name
Parent (2) Name (if applicable)
First Name
Last Name
Email
*
Phone
*
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Please tell me about yourself (strengths, weaknesses, likes, dislikes, personality traits, sensory preferences, etc).
What is your personal love language or how do you feel most loved?
Your Level of Physical Activity
Your Biological Rhythms (regularity of internal drives such as wake times, sleep, eating, toileting, etc.)
Your Level of Sensitivity (to environmental factors such as sound, light, touch, smell, taste, etc.)
Your Intensity of Emotional Responses (to changes, environment, etc.)
Your Level of Adaptability (to change, transitions, or new situations)
Your Level of Approachability or Withdrawal (to new people, environments, changes, situations, things, etc.)
Your Level of Persistence (with new or challenging tasks)
Your Level of Distractibility (to environmental factors such as sound, light, touch, smell, taste, etc.)
Your Mood (overall tone of feelings, interactions and behaviors, etc.)
Child's Name
Please tell me about your child. Who are they? What are their likes, dislikes, personality traits, sensory preferences, etc? What are their best qualities? What do you find most challenging about their personality?
What is your child's love language or how do they feel most loved?
Child's Level of Physical Activity
Child's Biological Rhythms (regularity of internal drives such as wake times, sleep, eating, toileting, etc.)
Child's Level of Sensitivity (to environmental factors such as sound, light, touch, smell, taste, etc.)
Child's Intensity of Emotional Responses (to changes, environment, etc.)
Child's Level of Adaptability (to change, transitions, or new situations)
Child's Level of Approachability or Withdrawal (to new people, environments, changes, situations, things, etc.)
Child's Level of Persistence (with new or challenging tasks)
Child's Level of Distractibility (to environmental factors such as sound, light, touch, smell, taste, etc.)
Child's Mood (overall tone of feelings, interactions and behaviors, etc.)
Additional Parent Notes (if needed)