Agape & Harmony Enrichment Center Pre-Screening Form

Section 1: Contact Information

Child's name

Child's birthday

Month

Day

Year

Parent/ Guardian's Name

Phone

Email

Emergency Contact (Name & Phone)

Section 2: Program Goals & Supports

What are your primary goals for your child in an enrichment program?

What does a successful day look like for your child?

How does your child communicate distress or discomfort?

What communication strategies work best?

Section 3: Communication

How does your child communicate distress or discomfort?

What communication strategies work best?

Section 4: Emotional Regulation & Calming Strategies

How does your child typically show signs of stress, frustration, or overwhelm?

Are there strategies that do not work or increase distress?

Section 5: Safety Awareness & Elopement

Does your child have a history of leaving supervised areas (elopement)?

Yes

No

Section 6: High-Intensity or Challenging Moments

When overwhelmed, how does your child typically respond?

Have there been situations where your child required additional adult support to maintain safety?

Are there early warning signs staff should recognize?

Section 7: Sensory Needs

Does your child seek:

Movement

Deep pressure

Quiet time

Section 8: Medical Needs & Health Information

Does your child have any medical conditions we should be aware of?

Yes

No

If yes, please describe:

Does your child take medication that may affect:

Does your child have an emergency action plan? (EAP)

Yes

No

Section 9: Family Collaboration

What strategies do you use at home that work well?

Are you open to consistency between home and program strategies?

What is the best way for us to communicate about your child’s day?

Section 10: Toileting & Personal Care Support

Does your child require adult assistance for any of the following? (Check all that apply)

Toileting routines

Handwashing

Changing accidents

Transitioning to/from the restroom

What best describes your child’s toileting skills? (Select one)

Section 11: Eating, Feeding & Mealtime Support

How does your child typically eat during program hours?

Independently

With reminders or encouragement

With adaptive utensils or supports

Does your child have any feeding considerations? (Check all that apply)

Selective or picky eating

Limited diet

Difficulty chewing or swallowing

Are there food allergies or dietary restrictions we should be aware of?

Yes

No

Section 12: Financial Responsibility

How do you anticipate paying for services?

Private Pay

Limited scholarship or financial assistance

Unsure/ would like more information

Are you able to meet the standard weekly program fees?

Yes

No

Agape & Harmony Enrichment Center does not deny enrollment based solely on financial need. Financial assistance is subject to availability, funding, and program policies.

Section 13: Acknowledgment

I understand that this pre-screening helps determine appropriate supports and program fit. I acknowledge that completion of this form does not guarantee enrollment.

Date

Month

Day

Year

Signature

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