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Applicant Questionnaire
Parent/Guardian Information
Parent/Guardian 1
First name
Last name
Address
Mobile phone
Work phone
Email
Parent/Guardian 2
First name
Last name
Address (if different)
Mobile phone
Work phone
Email
Your Child's Basic Information
First name
Last name
Date of birth (month/day/year)
Siblings
1. Name
Age
Gender
M
F
2. Name
Age
Gender
M
F
3. Name
Age
Gender
M
F
Your Child's Health History
Diagnosis (what it is, when it was given)
History of epilepsy or seizures
Surgeries
Botox treatments
Special diet
G-tube
Hearing
Vision
Current therapies (PT, OT, speech, other)
History of participation in Conductive Education programs
Special equipment (braces, splints, chairs, etc.)
Parents' Observations of Their Child
Child's favorite leisure activities
At home
Outside home
Favorite toys/games
It is
easy
difficult to motivate the child
Child is best motivated by
peers
toys
songs
other
Please specify if other
Child expresses wishes or needs with
Facial expressions
Gestures
Sounds
Words
Sentences
Other
Does the child follow instructions?
Most recent cognitive achievements
How does your child move around the house?
How does your child move around outside?
My child can
Roll over
Creep
Crawl
Kneel up
Sit up
Sit on the floor
Sit on a chair
Stand up
Take steps
Can your child negotiate stairs? How?
Can your child use both hands?
My child can reach for a toy
with right hand
with left hand
My child can hold onto a toy
with right hand
with left hand
My child can release a toy
with right hand
with left hand
My child can transfer a toy from hand to hand
My child can clap his/her hands
My child can point with his/her index finger
right
left
My child can pick up a Cheerio with his/her
right hand
left hand
Describe how the child eats and drinks (including position when eating; problems with chewing or swallowing; special utensils; self-feeding)
Describe what stage the child is at regarding toilet training
Describe your child's participation in getting dressed and undressed
What do you think are your child's greatest difficulties at this time?
The child is currently enrolled in these programs (times per week; hours per session)
Please share any other information that you wish
Thank you very much for your interest in our program!
