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Child's First Name (Preferred)

Child's Last name

Email

Phone

Address

Birthday

Day

Month

Year

Diagnosis (if any)

Understanding & Comprehension

Understands Simple instructions with support

Understands Multi-Step Instructions with support

Needs support with all forms of guidance or instruction

Inconsistent Understanding

Little to No Understanding

Communication and Processing (How best does your child understand instructions?)

Visually (demonstrations and modelling)

Verbally

Physical Prompting

Processing Time: Does your child need extra time to respond when asked something?

Yes

No

What helps them understand best?

Experience in the water

Can your child

Enter the pool independently

Put their face in the water

Float in the water

Kick their legs in the water

Safety Awareness

My Child displays safe behaviour in pools

My Child displays unsafe behaviour in pools

My Child displays safe behaviour on poolside

My Child displays unsafe behaviour on poolside

My child displays inconsistent safety profiles near and in water

Risk Behaviours

My child may run or jump into water unexpectedly

My child may panic with water on their face

My child may cling / freeze

My child may panic with unexpected physical contact

Sensory Profile

My child is sensitive to water on their face or in their eyes and ears

My child is sensitive to Noises and Echoes

My child is sensitive to temperatures

My child is sensitive to physical touch

Sensory Seeking

My child is sensory input seeking (Jumping, Splashing)

My child is avoidant of sensory input (Withdraw/Distress)

My child displays a mixed profile of seeking / avoiding sensory input

Triggers and Distress Signs

Loud noises could distress my child

Waiting and Transitions may upset my child

Other

Information about Triggers and Distress

Regulation and Support Strategies

My child benefits from a predictable lesson routine

My child benefits from a parent nearby who may be able to assist in regulation

My child has specific phrases or actions that aid regulation

Information about Support Strategies

Medical Concerns (if any)

Anything else you would like us to know?