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INTAKE INFORMATION FOR FUSE [FORCE] PARTICIPANTS
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Email
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Your email
Participant's Full Name
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Your answer
Parent's Name
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Your answer
Parent's Phone Number
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Your answer
Participant's Age
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Your answer
What is your preferred location?
West Bloomfield
Royal Oak
Both are OK
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What days would you like to workout?
Saturday AM
Tuesday PM (after school)
Thursday PM (after school)
Other:
PLEASE DESCRIBE YOUR CHILD’S STRENGTHS AND CHALLENGES
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Your answer
DESCRIBE YOUR CHILD’S VERBAL SKILLS
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Your answer
DESCRIBE YOUR CHILD’S MOTOR SKILLS
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Your answer
DESCRIBE YOUR CHILD’S SOCIAL SKILLS
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Your answer
HOW WELL IS YOUR CHILD ABLE TO FOLLOW GROUP INSTRUCTION?
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Your answer
DOES YOUR CHILD HAVE ANY SENSORY ISSUES? PLEASE EXPLAIN.
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Your answer
DOES YOUR CHILD HAVE ANY BEHAVIORAL ISSUES?
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Your answer
DOES YOUR CHILD HAVE ANY MEDICAL OR PHYSICAL CHALLENGES WE SHOULD KNOW ABOUT?
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Your answer
WHAT ARE YOUR CHILD’S INTERESTS AND MOTIVATORS?
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Your answer
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