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Caregiver Information

Yes / No

Child's Information

Male / Female
Yes / No
Yes / No
Yes / No
Yes / No

Please complete the following:

  • General Education Setting
  • Specialized Classroom Setting
  • 1:1 Therapy
  • Part Time Early Intervention
  • Full Time School Program
  • Social Skills Group Therapy

Therapy Services

Does your child currently receive any of the following services, or has he or she received them in the past?

Currently / In the Past
Currently / In the Past
Currently / In the Past
Currently / In the Past
Currently / In the Past

Communication

How does your child communicate with others?

  • Points or gestures
  • Uses sign language
  • Single words
  • 2-4 word phrases
  • Full sentences
Yes / No
Yes / No

Receptive Language

Yes / No
Yes / No
Yes / No

Behavior

Yes / No
Yes / No
Yes / No
Yes / No

Social Interactions

Yes / No
Yes / No

Academic Levels

Yes / No
Yes / No

General Information

Yes / No

Please select:

  • IEP Plan
  • 504 Plan
Yes / No

Do you know your child’s matrix code?

Unknown / 251 / 252 / 253 / 254 / 255

Funding Information

Yes / No / Not sure
Yes / No / Not sure
Yes / No
Yes / No
Yes / No

* Please note that the McKay Scholarship, SUFS Gardiner Scholarship, insurance and other scholarship opportunities may not cover the full cost of your child’s programming. Scholarship funding is not guaranteed. *

5860 Golden Gate Parkway
Naples, Florida 34116
(239) 352-7600