Individualized
Family Form
Guide
This guide is designed to help you describe your child (of any age) in detail by spurring thoughts of the little tricks that you’ve learned lead to more successful interactions. Sharing this with potential respite providers in advance should help
them to feel more prepared and make the time with your child more successful. Additional copies of this form can be downloaded at www.autismnj.org. Suggestions for Completing the Guide • Be specific! The more detailed information, the better.
• Update the information as your child grows. • Keep a copy in an easily accessible place. • Encourage providers to bring this guide if they leave the house with your child. • Although you are offering as much information as possible, remind providers to still expect the unexpected! Emergency Information • Phone numbers Name Number(s) Name Number(s) • Under what circumstances to call (check all that apply) Only in case of emergency If (s)he becomes upset and can’t be consoled If (s)he becomes aggressive If the provider is unable to locate something (s)he wants/needs General questions Other reasons: • Emergency contacts if parents/guardians are not available Name Number(s) Relationship: Name Number(s) Relationship: • Preferred hospital Doctor’s name, office address, and phone number
Insurance company, name of policy holder, and policy number
Medical release form (if needed)
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