Platte County On-Site Therapy Consult

First Name

Last Name

Phone

City

State

Postal Code

First Name

Last Name

My loved-one

My loved-one lives

School Information

School District (if applicable)

School/Grade Level (if applicable)

CDDO

Are you connected with Platte County Board of Services (PCBS)?

YesNoI would like support to get connected with Platte County Board of Services (PCBS).

Does your loved-one have a support coordinator?

YesNoI would like more information regarding support coordination.

Emotional Regulation Challenges

In your own words, please describe the challenge(s) related to your loved-one's emotional regulation.

When distressed, does your loved one require more support than same-aged peers to engage in appropriate coping strategies?

YesNo

Please describe your loved-one's current coping strategies.

Toileting/Hygiene Challenges

In your own words, please describe the challenge(s) related to your loved-one's toileting/hygiene.

Does your loved-one require more support than same-aged peers to complete dressing, grooming, and/or hygiene tasks?

YesNo

Please describe the challenge(s) related to your loved-one's toileting.

Please describe any strategies that have been used to address the challenge(s) related to your loved-one's toileting.

Visual Supports

In your own words, please describe your visual support needs.