Supportive Services Form

Address

Primary Area of Concern (or diagnosis if applicable)

Secondary Area of Concern (if any)

If yes, describe physical reaction during

If yes, describe reaction after

If yes, describe seizure plan

Treatment

Will this individual take any medications during program?

If yes, please describe medications

Personal and Community Skills

What have been this individual's/your family's experiences with church?

What Christian concepts does the individual understand (God, Jesus, church, Heaven, etc.)?

What Christian concept do you wish this individual could better understand?

If yes, describe unusual fears or concerns

Please explain any tips or techniques we could use to offer the best possible experience for this individual (food, verbal praise, toys, etc).

Any other information that would enhance or limit the participation for this individual (soothing techniques, sensory breaks, etc).

Work Entry