Gifted Hands Pre-Interview Questionnaire

This form is meant to provide the initial information about your child and family Gifted Hands Ministry needs to start the process of welcoming your child and your family into our ministry group. Once you submit this form our Gifted Hands Ministry coordinator, Yngrid, will reach out to set an appointment to show you our ministry space, answer your questions, and to get to know your child/family better, prior to your child participating in a Gifted Hands Sunday. We look forward to opening our arms to your family!

 











Child's Basic Information:
 Child's Name:
     
 Child's Birth Date:
     
Child's Gender: FemaleMale
My Child Is:VerbalNon-Verbal
 Language Spoken At Home? 
Family Information
Home Address:
complete home mailing address
Home Phone: 
Siblings YesNo  
Mother's Name: 
Mother's Cell Phone: 
Mother's E-mail: 
Father's Name: 
Father's Cell Phone: 
Father's E-mail: 
Guardian's Name: 
Guardian's Cell Phone: 
Guardian's E-mail: 
Emergency Contact:   
Child's Health & Disability Details
Child's Official Diagnosis

To participate in Gifted Hands Ministry it is necessary to have a diagnosis from a medical doctor.
Any food allergies?

What are your child's negative triggers?
Light, Sound, etc.
What are your child's stimming behaviors? (check all that apply)
hand flappinghand clappingrockingrepeating wordstwirling objectsflicking fingershead bangingpacingstaring at lightsother (please list)

Is stimming allowed? YesNo
Any time a child creates a safety concern for themselves, other children, or volunteers, you will be contacted via text.  That being said, are there any behavior points where your wish to be contacted otherwise?  At what behavior limits, short of safety concerns do you wish to personally intervene?



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