Access Ministries Teen/Adult Intake Form

Please provide information on the teen/adult with special abilities. All information given will be used to support and serve the teen/adult listed on this form.

Your name *

Email address *

Phone number *

Birthdate *

Address *

Add Other Household Members

Household members

Name of teen/adult with disability/diagnosis. *

Please list his/her favorites and strengths: *

ex. snacks, toys, activities, games, etc.

Please list any challenges, behaviors, or triggers: *

Please provide any suggestions or strategies on any challenges, behaviors, or triggers, to help assist during any possible situations: *

How does he/she communicate best when giving or receiving information: (Click all that apply) *

Auditorily (hearing)

Visually (seeing)

Kinesthetically (hands on)

Other

Are there any "accommodations" he/she are currently receiving? *

Currently, please explain the environment he/she participates academically and socially. *

Academically- A small group of students with a 5 to 1 ratio
Socially- participates with other students playing on the playground, building blocks, coloring, etc.

Does he/she have seizures? *

Does he/she have any food allergies?

Is there anything else you would like us to know about him/her? *

Parent/Guardian Signature *

Please fill in your first and last name.