Matthew's Ministry - Plan of Care

Church of the Resurrection

Information document for individuals with special needs care plan

Today’s Date: ______

Full Name of Matthew’s Ministry child/youth/adult:

Date of Birth______

Family Information: Please print.

Address:______

City/State/Zip:______

Home phone #______Cell phone#______

Email: ______

Father’s Full Name ______

Home Address if different from above:______

Employer:______

Work Phone:______

Mother’s Full Name:______

Home address if different from above:______

Employer:______

Work Phone:______

If child lives with a caregiver, please list primary caregiver information, as well

Children Living at Home: Please list all children

Child #1: Full Name: ______

Male/Female:Date of Birth:

Name of School:Grade:

Child # 2: Full Name:

Male/Female:Date of Birth:

Name of School:Grade:

Child #3: Full Name:

Male/Female:Date of Birth:

Name of School:Grade:

Special Needs High School Graduates: Please describe your post high school education or employment:

______

Profile of Child/Youth/Adult with Special Needs

Briefly describe your child’s disability:

______

Contacts/Assistance in the Community:

Please list primary physician name, address and phone number:

______

Medical Information:

Procedures to follow in case of an emergency:

Health Insurance Co.______ID #______Group #______Hospital Preference______

*If you have a medical plan of care for emergencies, please attach a copy for us. The same plan that you have for school or a daycare provider is acceptable.

Please indicate your child’s height______and weight______.

Please list medications that are taken on a regular basis.

MedicationWhen TakenHow is it administered?

Allergies to medications or environmental allergies (i.e. bee stings)

AllergySeverity of ReactionAction Steps

Please list any medical or special precautions for managing the following concerns and please check any that apply and explain.

Seizures

G-Tube

Trach

Positioning

Respiratory

Communication Needs:

Can communicate with others using:

Speech: ___Words ___Phrases ___Sentences ___Babbles ___Gestures ___Sign Language

___ Other (describe______

Can understand what others say:

___ All the time ___ Most of the time ___Some of the time ___Recognizes voices of family

Dietary/Feeding Needs/Eating Habits:

Feeds by using: ___ spoon ___ fork ___ hands ___requires feeding ___bottle fed ___ drinks from cup: ___with assistance ___by self

Eating schedule:______

Special diet :______

Foods to avoid/Allergies to foods or medications:_____

If your child is difficult to feed, please describe any special assistance or adaptive utensils required for eating: ______

______

Toilet/Hygiene Needs:

___ Toilets independently ___Diapers:___Cloth ___Disposable

___ Currently being potty trained ___ Potty trained, needs assistance

___ Requires catheterizationFrequency/Schedule:______

How does your child indicate a need to use the toilet?______

______

Indicate special toileting needs/schedule:______

______

Behavior Management:

Check all that apply

___shy ___outgoing___is sometimes destructive

___plays alone ___plays in groups___sometimes threatens others

___adapts to new situations well___sometimes hits, bites or hurts self/others

___adapts to new situations with difficulty___sometimes attempts to run away

___responds to correction well___hyperactive and /or ADD

___responds to correction with difficulty

Behavior Concerns:

Please share any behaviors we should be aware of (i.e. aggressive behavior, tantrums, wandering):

______

Behavior Modification Plan: (May attach school management plan)

Please explain in detail the behavior management plan being used at home and school to modify inappropriate behavior that may be exhibited. Our goal is to maintain consistency in the implementation of this plan:

My child responds to separation from his/her parents by: ______

My child is best comforted by: ______

My child lets someone know what he/she wants or needs by:______

______

What type of play activities does your child enjoy or participate in? ______

______

My child becomes upset when/or does not enjoy:______

______

Are there any other concerns not already addressed? ______

______

Declaration of Consent

Please indicate your consent to each item by signing below each statement.

Emergency Medical Treatment Consent

I, ______, parent/guardian of ______give permission to the medical personnel selected by Church of the Resurrection to order hospitalization, treatment, anesthesia, and surgery if necessary in case of an emergency when parents cannot be reached.

SignatureDate

Photograph Release Consent

I, ______, parent/guardian of ______give Church of the Resurrection permission to use my child’s name and/or picture in presentations, media releases, newsletters and marketing materials solely for the purpose of promoting Matthew’s Ministry at Church of the Resurrection.

SignatureDate

Waiver of Liability Consent

I, ______, parent/guardian of ______agree to release Matthew’s Ministry of Church of the Resurrection and all staff and volunteers from all liability for any additional illness or injury to my child, and for any accidental damage or destruction of my child’s property during the provision of respite care services.

SignatureDate