RISE Form

Your name *

Email address *

Phone number

Child's Name *

Child's Age / Birthdate / Grade *

My child has the following diagnosis, medical condition, or learning differences: *

My child is potty trained: *

Is your child prone to seizures? *

My child’s main mode of functional communication is:

My child can do these things independently:

My child needs assistance with:

My child is uncomfortable with or has an aversion to:

A trigger point for a potential meltdown is when:

When/If my child experiences a meltdown, he/she calms when:

Doing/Seeing/Experiencing this one thing is an important part of my child’s routine:

My child’s behavior may indicate a medical problem requiring immediate attention when:

My child has the following allergies and/or food sensitivities

If your child has food allergies, are they life threatening? Does your child use an epipen? *

Household members