Name *

First Name

Last Name

Phone

(###)

###

####

Please select any of the following diagnoses your child has been given: *

Cerebral Palsy

Epilepsy

Spastic Quadrapeligia

Intellectual Disability

Traumatic Brain Injury

Neurodegenerative Disorder

Genetic Syndrome

Other

Your child's experience with movement and coordination: *

No difficulty with movement or coordination

Mild difficulty with movement or coordination

Moderate difficulty with movement or coordination

Severe difficulty with movement or coordination

Your child's experience with learning and understanding: *

No difficulty with learning and understanding

Mild difficulty with learning and understanding

Moderate difficulty with learning and understanding

Severe difficulty with learning and understanding

Your child's medical complexity: *

Requires minimal medical attention or intervention

Requires occasional medical attention or intervention

Requires regular medical attention or intervention

Requires intensive medical attention or intervention

How much assistance does your child require with activities such as dressing, bathing, or eating? *

Requires no assistance

Requires little assistance

Requires some assistance

Requires lot of assistance

Which option best describes the permanence of your child's impairment? *

Temporary and expected to improve over time

Permanent but stable (static)

Permanent and getting worse over time (progressive)