This is the child who needs support from HHT for his or her special needs.

Client Age: Number *

Client Date of Birth *

Client Gender at Birth *

female

male

Client's Disabilities or Special Needs *

Client Dislikes / Triggers *

Client Interests / Likes *

Client Communication Ability *

Client Communication Method *

Has the client been physically aggressive with people or animals? *

Physical Aggression: Tell us more ... *

Food Allergies / Restrictions: Check all that apply.

Food Allergies: Additional Info

Epi-Pen: Does the client carry/use one? *

yes EpiPen

no EpiPen

EpiPen: Additional Information

Diagnoses & Treatment

Let's get some detail on your child's 3 most pertinent diagnoses or disabilities, whether actual or suspected. We provide space for further diagnoses in a following section.

Name of Diagnosis 1 *

Symptoms of Diagnosis 1 *

Applied Treatments for Diagnosis 1 *

What is the most pertinent 2nd diagnosis--actual or suspected? Please give the name of the condition, symptoms you see, and treatment you apply or have tried.

Symptoms of Diagnosis 2

Applied Treatments for Diagnosis 2

What is the most pertinent 3rd diagnosis--actual or suspected? Please give the name of the condition, symptoms you see, and treatment you apply or have tried.

Symptoms of Diagnosis 3

Applied Treatments for Diagnosis 3

If you have or suspect further diagnoses, fill us in.

Support & Structures

Positive Reinforcements / Motivators *

Structures / Supports *

Therapy 1 - Outcome *

Therapy 1 - Protocol

Therapy 2 - Outcome *

Therapy 2 - Protocol

Additional Clients Needing Support

Client 2 - Firstname

Client 2 - Birthdate

Client 2 - Diagnoses

What does the primary caregiver need? Check ALL that apply. *

What is the #1 need of the primary caregiver. Check one. *

Support Tier *

Choose your support tier. For families needing support for more than one child, allow at least one Volunteer Therapist per child.

The primary parent is the one who will interface most frequently with HHT.

Primary Parent's Relationship to the Client *

Primary Parent's Marital Status *

Primary Parent's Occupation *

Primary Parent's Workplace or Employer *

Secondary Parent or Adult

The secondary parent will interface with HHT less frequently, and it can refer to either a parent (in-home or not) or another adult (grandparent, guardian, etc.) who lives in the home with the supported child.

Secondary Parent's First Name

Secondary Parent's Last Name

Secondary Parent's Role

Secondary Parent's Residency

Secondary Parent's Mobile Phone

Secondary Parent's Email

Start with the oldest and work down in age. Please also include stepsiblings & cousins living in the home.

Sibling 1 - First and Last name

Sibling 1 - Relationship

Sibling 2 - First and Last name

Sibling 2 - Relationship

Sibling 3 - First and Last name

Sibling 3 - Relationship

Sibling 4 - First and Last name

Sibling 4 - Relationship

Siblings 5, 6, 7 and so on.

We understand there are many constellations of family. If you have a non-nuclear or non-typical situation, please fill us in with information that you would like us to know or that would be relevant to the support situation. For our founder's case, she may write: "Divorced. Single mom. Child visits his father alternating weekends [Fathers name, mobile phone, work phone, occupation, place of employment, etc]. HHT will not need to interface with the child's fathers except on visitation Saturdays during therapy sessions, which will be virtual on those occasions."

Local Emergency Contact

First Name of Emergency Contact 1 *

Last Name of Emergency Contact 1 *

Emerg_Contact_1 Address *

First Name of Emergency Contact 2 *

Last Name of Emergency Contact 2 *

Emerg_Contact_2 Phone *

Primary Care Physician

Physician's First Name *

Physician's Last Name *

Physician's Clinic Name *

Health Insurance Provider *

Health Insurance Provider Phone *

Health Insurance Subscriber Name *

Health Insurance Group # *

Health Insurance Policy ID# *

Comments, questions, or additional information ...

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