Questionairre | Special Me

Special ME!

Respite Care Questionnaire

Helping us care with compassion and confidence.

Parent/Guardian Name(s)

Child's Full Name:

Phone

Are there any special routines or rituals

What are your child's srengths and interests?

What does your child enjoy doing the most.

Does your child communicate verbally?

What usually helps your child calm down when they're upset?

What typically triggers your child's frustration, anxiety, or meltdowns?

How does your child respond to new people or environments?

What are some behavioral concerns (if any) we should be aware of?

Are there strategies that have worked well for you when managing challenging behaviors?

Are there any safety concerns (e.g., running off/elopement, aggression, self-injury)?

Does your child have any allergies (food, medication, environment)?

Are there any dietary restrictions or food sensitivities?

Does your child take any medications? (If yes, list name, dose, and time given)

Are there any medical conditions or concerns we should be aware of?

In case of emergency, who should we contact? Individual Needs & Preferences

Are there any non-negotiables or must-haves during care?

Preferred days/times for respite care:

Do you prefer in-home or community-based respite?

Is transportation needed or provided by the family?

Are there pets in the home?

Will anyone else be present during respite sessions?