Special Needs Ministry Intake Forms

I have seen a handful of special needs parent questionnaires and they all differ. Some churches have very detailed intake forms that look like something a skilled professional would complete inside a patient’s file.  Other churches ask one or two open ended questions that may fail to draw out critical information.  Below is a list of idea-starters for an intake form.   I personally like it when a representative of the church goes through the questions one-on-one with parents.  This conversation can ease the mind of a family who fears that an honest answer about their child may yield rejection from the church.  In addition,  I do think it is important for the parents to complete this form themselves and in writing.  This practice ultimately protects the child and the church.

Keep in mind that certain terms and local practices within nearby schools may influence the questions and wording on an intake form.  It might be helpful to ask a contact from a local school to review your church’s questionnaire.  Organizations that equip churches for respite are also excellent sources for help.  Last but not least, the church’s attorney and insurance carrier may offer guidance for all special needs-related ministry forms.

**Please note that I am not an attorney nor a credentialed professional from the medical or educational fields.  Please do not rely on this post (nor any post on this blog!) as your sole source for developing good practices for special needs accommodation.  Part of good planning includes proactively contacting your church’s attorney and insurance carrier to discuss potential policies & procedures.**

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Parent Questionnaire for Children with Special Considerations:

Our church cares for each participant in children’s ministry programming.  These questions are asked for the benefit of your child and so that we may provide the best experience and safest environment for everyone involved.  Our church and our children’s ministry workers respect your family’s right to privacy. Any information shared from this form is communicated directly with those caring for your child and only on a “need to know” basis.   Please answer the below questions that apply to your child and that may help our church best minister to your child.

• My child has the following diagnosis, medical condition or learning difference:
• My child has the following allergies and/or food sensitivities:
• My child’s allergies can be life threatening (circle) Yes/No and require the use of an EpiPen Yes/No
• My child’s main mode of functional communication is:
• My child processes instruction or information best when:   (e.g. visual, auditory, experiential, drama).
• My child currently receives therapies and special instruction in:
• My child has an Individualized Education Plan Yes/No
• If answered “yes”, please describe child’s IEP:
• The goals I have for my child’s development this coming year include (behavioral, social, academic, etc):
• My child has the following area(s) of interest:
• 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 melt-down he/she calms when we:
• Doing/seeing/experiencing this one thing is an important part of my child’s routine:
• My child (circle one) does/does not enjoy music
• My child seems most relaxed in settings (circle one) alone, with a few children, among many children
• My child (circle one) would/would not enjoy a large group worship experience
• My child is really picky about:
• My child may be trying to communicate their need for (describe) ______ when he/she exhibits the following behavior:
• My child is prone to seizures (circle one) Yes/No  If yes, tell what prompts the seizure and how we can prevent/respond:
• My child’s behavior may indicate a medical problem requiring immediate attention when:

For two sample intake forms/parent questionnaires, see the following two posts:

Conducting a Parent Interview for Special Needs Ministry Intake Forms

Best Practices:  Spotlight on Johnson Ferry Baptist Church Part 1

Developing a Special Needs Ministry’s Goals & Mission.

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– Amy Fenton Lee