Dreams With Wings Big & Small Application

Welcome to Dreams With Wings Big & Small program for children ages 2-6 and their caregivers!

Please complete this form to begin the on boarding process as a prospective new client for our

Big & Small is designed as a joyful play circle for young children and their caregivers to explore music, movement, and books in a warm, playful group setting. With a caregiver present and actively participating, families will sing, move, read, and play together while building connection, communication, and early social skills.

Perfect for little ones who already love music, stories, and shared play with a wonderful opportunity to start the journey of social engagement.

Caregivers are required to attend each session to learn, connect, and build relationships alongside their children.

Big & Small is offered as a 4 week series for a small group to keep the experience intimate, engaging, and supportive. Perfect for little ones who already love music, stories, and shared play; and wonderful opportunity to start the journey of social engagement.

Applicant Information

Applicant's first name

Applicant's last name

Applicant's DOB

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

County (e.g. Jefferson)

Does the applicant attend pre-school, daycare program, elementary school, homeschooled etc.? If so, what is the name of the school, program, etc.?

Caregiver Information

Parent/Guardian's First Name

Parent/Guardian's Last Name

Primary Phone Number

Primary Parent/Guardian Email

Would you like to add an additional Parent/Guardian?

Yes

Will you be using Private Pay or Respite (Michelle P Waiver)?

Private Pay

Respite (Michelle P Waiver)

Is the applicant on the Michelle P Waiver Wait List, meaning you have applied for the waiver but have not yet been approved?

Yes, s/he IS on the wait list

No, s/he is NOT on the wait list

Medical Information

Does the applicant currently have a diagnosis?

Yes

The applicant is on a wait list to begin assessment for diagnosis.

The applicant has not received a diagnosis.

Applicant's Primary diagnoses

Does the applicant require hand-over-hand teaching?

Can the applicant ask for help?

Yes

What types of ambulation needs does the applicant have? If none, enter N/A.

Behavioral Information

Please list any other behaviors not mentioned above that we should be aware of so that we can provide the level of support needed. If none, enter N/A.

Emotional Responses (check all that apply)

List things that scare or upset the applicant:

Please describe what helps to calm the applicant when s/he is sad, afraid, hurt, upset, etc.

Sensory Responses

Activity Levels (check all that apply)

Has typical attention span and level of activity for his/her age

Has a short attention span

Less active / needs motivation to participate

Overactive

Easily distracted by sights, sounds, people, etc.

Other

Please list any undesirable activities for your applicant. Please be specific.

What are the applicant's strengths?

Additional Information

What would you like for the applicant to get out of her/his experience at Dreams With Wings?

Is there anything else we should know about the applicant to make their experience a great one? The more we know about her/his likes/dislikes, skills, needs, behaviors, the better we can serve her/him.

How did you hear about Dreams With Wings?

Internet Search

Word of mouth

Referral from case manager

Referral from another organization (ex: FEAT, Council on Developmental Disabilities, etc.)

Social Media (Instagram, Facebook)

Other

Applicant Information

Caregiver Information

Payment Options

Medical Information

Communication

Behavioral Information

Sensory Responses

Activity Levels

Additional Information

Applicant Information

Caregiver Information

Payment Options

Medical Information

Communication

Behavioral Information

Sensory Responses

Activity Levels

Additional Information