CE APPLICATION

New child/youth client request

PLEASE COMPLETE ENTIRE APPLICATION

If you are interested in receiving Conductive Education services for a child or youth please complete the application form below. Our conductors will review the information and then followup with you.

After you’ve completed the application, please take some videos that would allow us to see how the child/youth does with the following tasks:

  • Lying on belly and back
  • Rolling over and turning around
  • Sitting up, sitting (both unsupported and supported)
  • Standing up, standing (okay to use whatever equipment they are used to)
  • Communicating (can be verbal communication or use of device)
  • Manipulation (holding things, playing with a puzzle, etc.)
  • Self-care (feeding, buttons, zipper on coat, etc.)

When it’s convenient and a prospective child is local we typically meet with families so we can assess the child and understand their current capabilities and limitations so that we can prepare a program that will meet their specific needs and group them appropriately.  However, when a family lives far away we simply initiate this process via videos. Videos can be emailed to assessments@sarasgarden.org.


Child's Personal Information

Child's Name *

Gender *
FemaleMale

Date of Birth* (ie: 01/04/2014)

Street Address *

City*

State *

Zip Code *

Child Lives With


Mother/Guardian Information

Mother's Name *

Street Address (If different than child)

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address


Father/Guardian Information

Father's Name *

Street Address (If different than child)

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address


Sibling Information

Name

Age

Gender
FemaleMale

Name

Age

Gender
FemaleMale

Name

Age

Gender
FemaleMale


Medical and Health Record

Mother's Age at Time of Birth *

Gestation Weeks *

Child’s Weight at Birth *
Apgar Scores *

Family History
Are there any illnesses / disabilities in the family?

Child’s Diagnosis
What is it; when was it given?

Any History of Epilepsy or Seizures?
What kind; how often; how long; main symptoms?

Current Medications

Surgeries
What kind; when?

Allergies
Food, medications etc.

Special Diet
G-tube, etc.

Hearing Tested and Results
When/what results?

Vision Tested and Results
When/what results?


Date of Last Medical Exam(s)

Pediatrics (ie: 01/04/2014)

Ophthalmologist (ie: 01/04/2014)

Neurologist (ie: 01/04/2014)

Ear-Specialist (ie: 01/04/2014)

Orthopedics (ie: 01/04/2014)

Dentist (ie: 01/04/2014)

Previous Treatments & Therapies
PT, OT, Speech, other services; how often?

Past Participation in Conductive Education Programs?
When, where?

Other Information / Comments you would like to share


Parent/Guardian Observations

Describe Child’s Daily Routine
(Weekdays)

Describe Child’s Daily Routine
(Weekends)

Child’s Favorite Leisure Activities in the Home

Child’s Favorite Toys / Games

Child’s Favorite Outdoor Activities

Does Child Take Part in Family Life?
Does he/she do small household jobs?

How Does Child Express Wishes or Needs?

Does Child Speak Words and Sentences Fluently?

Does Child Follow Instructions?

How Does Child Move Around Indoors?

How Does Child Move Around Outdoors?

Can Child Navigate Stairs?

What are Child's Greatest Difficulties at This Time?

Is it Easy or Difficult to Motivate Child?
What does motivate him/her (peers, toys, songs...)?

What Kind of School / Program is Child Currently Enrolled?

How Many Times a Week Does Child Attend and for How Many Hours at a Time?

What Kind of Activities Does Child do While at School?

Please Share any Other Information you Would Like.


Present Physical Condition

Lying Position - Is he/she able to:
Lift HeadRoll OverCrawl

Sitting Position - Is he/she able to:
Sit on the FloorSit in a Chair (Supported)Sit in a Chair (Unsupported)

Standing Position - Is he/she able to:
Stand up From the Floor?Stand (Supported)Stand (Unsupported)

If So, Please Describe:

Walking
Is Child Able to Take Steps? If So, Please Describe:

Fine Motor Movement
Is he/she able to grasp and hold different things (blocks, pencil, paper, etc.)?

Self-Reliance
Describe how he/she eats and drinks (is there any problem with chewing or swallowing; special utensils, self-feed).

Describe Child's Stage in Toilet Training

What Special Aides, Furniture Does Child Use at Home?


General Questions

What Goals do you Have for your Child?

Do you Expect to Reach Goals with Conductive Education?

How did you Hear About Sara’s Garden?


Confirmation

This Application has been Completed by: *

Relationship *

Date * (ie: 01/04/2014)

Please Check to Confirm Authorization *
I am authorized to provide this detailed medical information on this child to Sara's Garden for consideration in their CE program. Upon review Sara's Garden will contact me regarding an assessment date.

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Contact Us

<p style="text-align: justify;">If you have any questions or would like to receive any additional information on our Sara’s Garden here at Sara's Garden, please feel free to contact us. We would love to address any questions you may have.</p>

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