smile intake form

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5601 Sunnybrook Drive; Sioux City, IA 51106 sunnybrookchurch.org SMILE Special Ministry Includes Loving Everyone Registration Form & Questionnaire for Individuals with Additional Needs Sunnybrook Church cares for each participant inside our family ministry. These questions are asked for the benefit of the participant, and so that we may provide the best experience and safest environment for everyone involved. Our church leaders and our ministry volunteers respect your family’s right to privacy. Any information shared from this form is communicated directly with those caring for the participant and only on a “need to know” basis. Please answer the below questions that apply to the participant and that may help our church best minister to the participant. Form Completed By: _________________________________________

Date: _________________

Participant Name: ______________________________________________ D.O.B.:__________________ Contact Person/Agency:______________________________________________Phone_____________________ Email Address:_________________________________________________________________________ The participant has the following diagnosis, medical condition or learning difference:

The participant has an individual formal plan: The participant has a direct care provider:

YES YES

NO NO

If YES, what do they assist with? What do their responsibilities include?

The participant has the following allergies and/or dietary requirements:

The participant’s main mode of functional communication is:

The goals for the participant’s development this coming year include (behavioral, social, spiritual, etc.):

The participant has the following area(s) of interest:

The participant can do these things independently:

The participant needs assistance with:

The participant is uncomfortable with or has an aversion to:

A trigger-point for resistance, frustration, or behavioral problems may emerge for the participant when:

When/if the participant experiences a period of frustration, he/she calms when we:

The participant (circle one) does / does not enjoy music. The participant seems most relaxed in settings (circle one): alone

with a few people

among many people

The participant (circle one) would /would not enjoy a large group worship experience. The participant may be trying to communicate their desire/need for (describe)__________________________ when he/she exhibits the following behavior:

The participant is prone to seizures (circle one): YES / NO The participant’s behavior may indicate a medical problem requiring immediate attention when:

Doing/seeing/experiencing this is an important part of the participant’s routine: Other information:

Which service do you typically attend? 8:30 10:00 11:30 *Please note that while we indicate that the SMILE ministry is available only during the 10:00 service, the buddy and participating family can decide which service works best for those involved.