New Jersey Statewide Parent to Parent
Support Parent Information Form

Date of Orientation:

Primary Caregiver

Relationship to Child:

Name:

Address:

County :

City: State : Zip:  

Home Phone (including area code):
Cell Phone (including area code):

Work Phone (including area code):

Email:

Race: 

Sex:

Language(s) Spoken:  

Occupation:

Marital Status:

Religion:

 

Significant Other

Relationship to Child:

Name:  

Home Phone (including area code):
Cell Phone (including area code):

Work Phone (including area code):

Email:

Race: 

Sex:

Language(s) Spoken:  

Occupation:

Marital Status:

Religion:

 

Child Information

Name:

Sex:   DOB:  

Primary Diagnosis or Disability:

Secondary Diagnosis or Disability:

Age of Onset:

Medications:

 

 

What else would you like us to know about your child?

 

Are there any other experiences that you are comfortable sharing with another parent?

Others living in your home: (please list birth dates of siblings)

Name                                               Birth date       Relationship to child

 

   
   
   


Please check all of the following that you or child has had experience with and you feel comfortable discussing with another parent:

Medical

preemie (no. of weeks )
sleep apnea
g-tube feeding
bradycardia
shunt
sleep issues
seizures
toilet skills
clean intermittent catheterization (CIC)
Surgery or procedure, please specify:

Special diet, please specify:
 Other

assistive technology     
advocacy
( mediation,  due process)
challenging behaviors
sibling issues
respite care
social skills  
after-school programs:
camps
community inclusion
School

early intervention
pre-school
general education class
in-class support
resource room pull-out
self-contained class
private school
home school		 Therapy

physical therapy
occupational therapy
speech therapy
vision services
applied behavioral analysis( ABA )
DIR/floor time
feeding
sensory integration
hippo-therapy
Hearing

hearing loss
mild ( one,  both)
moderate ( one, both)
severe to profound ( one, both) 		Communication Type

 ASL
oral
total communication
 Equipment

hearing aide
 cochlear implant
fm system

 

Clicking the submit button below indicates that I agree to abide by SPAN's Confidentiality Policy and give permission to have the above information used by this Parent-to-Parent program for the purposes of making matches with referred parent.