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Online Child Assessment Form

Please make sure to have access to this site while filling out the form as you will have to refer back to watch the walkthrough video and to choose days/times for lessons.

Child Assessment

Parent or Guardian Name *

Parent or Guardian Name

First

Last

Parent or Guardian Email *

Phone

Best way to contact you:

Email

Phone

Swimmer Name *

Swimmer Name

First

Last

GENERAL

Potty-trained? (no accidents in the past 6 months)

Yes

No

Occasional Accidents

Previous swim experience?

Yes

No

If Yes, where?

Current swimming ability?

Is your child okay with putting head in water?

Yes

No

Family has or vacations near:

pool

hot tub

lake

river

canal

boat

other

If Other, where?

Any incidents with water (fell in, hard to give baths, etc.)?

BEHAVIOR

Aggressive behavior?

Yes

No

If Yes, please explain?

Any behavioral strategies that would/have worked?

COMMUNICATION

Expressive (talking):

Verbal

Verbal (limited)

Non-Verbal

Sign Language

PECS

Other/Explanation

Receptive (understands) – Follows simple directions

Yes

No

Verbal

Written

Gestures

Receptive (understands) – Uses visual schedule

Yes

No

Written

Picture

Object

Other

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.

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