Support Parent Information Form

Support Parent Information Form

In the first section, please enter information about yourself. In the second section, please enter information about your loved one with a disability and/or special healthcare needs. Please remember that we use the below information to make the best match possible. The more information we have about your experiences, the best match we can make. Saying that, please provide us with as much information as you are comfortable. If you have any questions, please reach out to Jena Wells at Jena.Wells@cchmc.org. Thank you!

First Name

Last Name

Your Relationship to Child with disability and/or special healthcare needs:

Other Relationship Explanation

Mailing Address

City:

State

ZIP

County:

Email

Preferred Phone

Home Phone

Mobile

Work Phone

Best Time to Call

Gender

Other Gender Explanation

Ethnicity

Other Ethnicity Explanation

Race

African-American/BlackAmerican Indian/Native American/Alaskan NativeAsianCaucasian/WhiteNative Hawaiian/Pacific IslanderSome other raceTwo or more racesPrefer not to disclose

Race Explanation

Primary Language

Other Language

Secondary Language

Other Languages Spoken

Is an interpreter needed?

YesNo

How did you hear about Ohio Parent to Parent?

If Other Please Explain

Support Parent Training Completion Date:

Experienced with: What would you feel most comfortable talking about to another parent? (Please click all that apply.)

Diagnosis:

Autism Spectrum DisorderBlood DisorderBrain-relatedCancer & TumorCentral Nervous System DisorderChromosomal AbnormalityCraniofacial & DentalEars & HearingEndocrine DisorderEyes & VisionFeeding-Digestion-WeightGastrointestinal DisorderGenetic DisorderGenito-Urinary DisorderGrowth-Bone-Joint-Limb DisorderHeart Disease & DisorderInfectionsIntellectual DisabilityLearning DisabilityLiver, Gall Bladder, Etc.Lungs & BreathingMental Health DiagnosisMetabolic DiseaseMiscellaneousMitochondrial DiseaseMuscles-Movement-NeuromuscularSeizures & EpilepsySkin DisorderSpeech-LanguageSubstance Use-AbuseRare disease or diagnosisOther

Adaptations/Accessibility Services:

Accessible Living SpacesAccommodations & ModificationsAdaptive EquipmentAssistive TechnologyBrailleCanine AssistanceCaptioningCommunication DevicesDevelopmental ToysFeedingModified VehiclesOrthoticsSign LanguageSpecialized EquipmentTransportationUniversal Design

Behavior:

Abnormal sleep patternsAggressive/ViolentArgues/must have last word in exchangesBed wettingBites othersDefianceDepressionDoes not like to be huggedDoes not like to be touchedEasily frustratedElopmentGaggingHand bitingHead bangingInappropriate sexually-related behaviorsMotor TicsMuscle-twitchingNervous TicsPerseverative Language or soundsPhonic TicsPhysically runs away from peopleRapid mood changesSelf-AbusiveShirt biting/chewing shirtSocial Interaction ChallengesTalks or has talked about suicideTemper tantrumsToileting IssuesVerbally abusive

Camps and Recreation:

Activities - AfterschoolActivities – ArtActivities - EquestrianActivities - MusicCamps/DayInclusive ActivitiesCamps/OvernightCamps/SpecialtyCamps/SummerFaith Based ActivitiesRecreation ActivitiesSocial ActivitiesSpecialty CampsSports – AdaptedSports - InclusionSummer Activities

Communication:

NonverbalSign LanguageAugmentative Communication Device

Diet:

Casein free/Gluten freeFailure to ThriveFeeding TubeFeingold DietFood AllergiesGastrostomy TubeKetogenicRequires Feeding AssistanceOther diet

Community Resources:

County Board of Developmental DisabilitiesDisability Specific NonprofitEmployment ServicesFaith Based ResourcesFinancial AssistanceFuture PlanningGeneral Resource InformationGuardianship/Supported Decision Making/AlternativesHome Health ServicesImmigration IssuesIndependent LivingInterpretation ServicesLegal ServicesPost InstitutionalizationRespite CareSupport GroupTransportation Services

Family Background:

AdoptionFoster CareParenting - BlendedParenting - DivorceParenting - MarriedParenting - SingleSibling RelationshipsSingle Parent

Early Childhood Services:

Child Care ProgramsDay CareEarly InterventionHead StartHelp Me GrowItinerant ServicesMontessoriNICU/PICUPreschool Programs/SpecializedTransition to School

Education Services:

504AssessmentAssistive TechnologyBehavior IssuesBoard Certified Behavior Analyst (BCBA)Bullying-SchoolConference RegistrationCounselingDenied ServicesDue ProcessEvaluationExtended School YearFacilitated IEPFamily SupportFunctional Behavior Analysis (FBA)GiftedHomeschoolingIEPIFSPInclusionInformation (Please note)Least Restrictive EnvironmentMediationMedical EquipmentMontessoriNurseParent RightsParent Volunteer TrainingPlacement - Mental Health FacilityPlacement – Residential FacilityPost Secondary EducationPre-SchoolPrivate EducationPTI InformationRecordsReferral (please note)Related ServicesRequest for Material/InformationRequest for Parent Volunteer AssistanceRequest for WorkshopResolution MeetingRestraint/SeclusionRevocation of Special EducationRTI (Response to Intervention)School Based Mental HealthSchool Healthcare PlanSchool PlacementSibling SupportSurrogate Parent (School appointed)Surrogate ParentingSuspected DisabilitySuspension/ExpulsionTransition AdulthoodTransition InTransition OutTransportationTwice ExceptionalVocational EducationVocational RehabilitationWorkshop RegistrationWork Study

Equipment:

Assistive TechnologyBaclofen PumpColostomyCommunication DevicesCPAP/BIPAPHearing AidHeart MonitorIVKidney DialysisNebulizerOrthotics/AFO'sOxygenProsthesisRespiratorStanderSuctionTracheostomyVentilator

Healthcare Services:

Care CoordinationDevelopmental PediatriciansGenetic TestingGynecologyHome Health Care/Nursing ServicesMedical Air TransportMedical Home/Primary Care DoctorRehabilitation CentersSpecialists: CardiacSpecialists: NeurologySpecialists: OrthopedicSpecialists: PulmonarySpecialists: SleepSpecialists: UrologySpecialty: OpthamologyTransition to Adult Healthcare

Insurance Programs:

AppealsBureau for Children with Medical Handicaps (BCMH)Children's Health Insurance Program (CHIP)Choosing a Medicaid PlanInsurance/PrivateMedicaid/GeneralMedicaid/JFSSSIState-Based FundingWaiver - County BasedWaiver - Medicaid

Self-Care:

HygieneDaily Living

Mental Health/Behavior Services:

Behavioral PsychologistBoard Certified Behavior Analyst (BCBA)BullyingChild AbuseCounselingMental Health ServicesPsychiatristsPsychologistsSexual AbuseSelf Esteem

Toilet Skills:

Bedwetting/EnuresisCatheterizationConstipationIncontinence of RectumIncontinence of UrineLoose StoolsPotty Training

Planning for the Future:

Adult transition/servicesEmploymentGuardianship/Supported Decision Making/AlternativesPersonal Care AssistancePost InstitutionalizationPubertyResidential Adult FacilityResidential Group HomeSexualitySpecial Needs Wills and TrustsSupported/Independent LivingVocational/Rehabilitation

Pregnancy:

Genetic TestingMultiplesPrenatal Diagnosis

Procedure:

Adductor ReleaseAortic Valve ReplacementASD RepairAV Canal RepairBack ClosureBladder AugmentationBladder CatheterBody CastBone GraftBotox InjectionBone Marrow TransplantBowel ResectionBrain SurgeryBrain Tumor RemovalBroviac/Hickman CatheterCataract RemovalChemotherapyCleft Lip/Palate RepairClub Foot CorrectionCoarctation of the AortaCochlear ImplantColostomyCraniofacial ReconstructionCraniotomy, PartialECMOExstrophy Bladder ClosureEye SurgeryFistula RepairFontaine ProcedureFundoplicationGastrostomy/G-tubeHamstring LengtheningHeart CatheterizationHeart MonitorHeart SurgeryHeart TransplantHeart/Lung TransplantHeel Cords LengtheningHerniaHip SurgeryHysterectomyIleostomyImperforate AnusJJ OstomyKidney FailureKidney TransplantLiver TransplantLobectomy, Left TemporalMitral Valve RepairNew Pulmonary ValveNorwood ProcedureOomphaloceleOrthopaedicPatent Ductus Arteriosus surgery (PDA)Pulmonary Artery BandingRadiationRhizotomyShuntSkin GraftSpinal FusionSyndactyly ReleaseTE Fistula RepairTendon TransfersTongue ReductionTracheotomy ProcedureVagus Nerve StimulatorVesicostomyVSD Repair

Mobility:

Non-AmbulatoryParalysisRampsWalks with Supportive DevicesWheelchair

Therapies/Interventions:

ABA - generalABA - in schoolAquatherapyArt TherapyAssistive TechnologyBehavioralCognitiveDialectical Behavior Therapy (DBT)Eye Movement Desensitization and Reprocessing (EMDR)FeedingHippotherapyHyperbaric OxygenMusicOccupationalPhysicalPsychotherapyRapid Prompt Method (RPM)RespiratorySensory integrationSign LanguageSocial Skills TrainingSpeech/LanguageTrauma-Focused Cognitive Behavior TherapyVision

Medication:

Medication ProblemSteroid Side Effects

Other Information to be considered in a match:

Information about your Loved One with disability and/or special healthcare needs:

Loved One Section

Child/Adult First Name

Child/Adult Last Name

Child/Adult Gender:

Child/Adult Other Gender Explanation

Will you share your Loved One's Birthdate?

YesNo

Date of Birth

Birth Year

Premature?

YesNo

Weeks at birth?

NICU?

YesNo

NICU Weeks?

Child/Adult Ethnicity

Child/Adult Other Ethnicity Explanation

Child/Adult Race

African-American/BlackAmerican Indian/Native American/Alaskan NativeAsianCaucasian/WhiteNative Hawaiian/Pacific IslanderSome other raceTwo or more racesPrefer not to disclose

Child/Adult Race Explanation

Does the child/adult have a diagnosis/diagnoses?

YesNo

If so, when/where was diagnosis?

Who made the diagnosis?

Other diagnosis not listed below:

Primary Diagnosis

Loved One Primary Diagnosis Category:

Loved OnePrimary Diagnosis:

Secondary Diagnosis

Loved One Secondary Diagnosis Category:

Loved One Secondary Diagnosis:

Any other information pertinent about the child/adult:

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Contact Information