Parent or Guardian Email
*
Phone
GENERAL
If Yes, where?
Current swimming ability?
If Other, where?
Any incidents with water (fell in, hard to give baths, etc.)?
BEHAVIOR
If Yes, please explain?
Any behavioral strategies that would/have worked?
COMMUNICATION
Other/Explanation
If Other, please explain
How does your child learn best (picture cues, praise, sensory tools, hand-over-hand, etc.)?
SPECIAL INTERESTS
Sports
Music
Games
Books
Toys
Other
Positive reinforcers
Fears/dislikes
SENSORY
What sensory sensitivities does your child have?
Any sensory items/strategies that work well/help (squeezes, etc.)?
GOALS
What are some goals you would like to set for your child (put face in water, safety, float, strokes, comfortability, etc.)? Please list as many as you can:
If you are human, leave this field blank.
Submit