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Name*

First Last

Today's Date*

Date of Birth*

Disability/Diagnosis*

Things that I am good at/like to do:*

Things that I am not so good at/don't like to do:*

I communicate by using:*

Help me understand what you want me to do by:*

My social skills with my peers are:

Things that make me happy:*

Things that make me sad or mad are:*

You can tell that I am frustrated/upset when I:*

Things you can do to help me calm down:*

Behavior management techniques that work for me:*

My swimming skills are:*

Medical issues for me are (i.e. seizures, medications, etc.):*

My goals for the program are:*

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Sensory Painting

Halloween Party