(Please list every diagnosis and beside each one put (M) mild (S) severe)
(Please make sure their name is own any item that will be brought for the Church program cannot be responsible for damage or loss.)
• Seizure Type and Nickname
• What happens
• How long it lasts
• How often
• Triggers
• Other Seizure Treatments
• Device Type
• Dietary Therapy
• Any Special Instructions
Please list the initial behavior, as well as the medical problem that follows.
(For example - Does your child/young adult need noise head muffs, small scale activities in a class room away from lights, energy, and noise or they would like a large group activity. List favorite color, sport, sports team, if they have a pet and pets name, if they play a sport, musical instrument, or in a club etc. This area is important for conversion purposes and so we can do activities liked and try and avoid ones that are not, be specific.)
Please list the initial communication, as well as the behavior that follows.