PCCLift Behavioral Support Plan | Perinton Community Church

PCCLift Small Group Behavioral Support Plan

In order to best serve your child with special needs please complete the following questions. Please complete a separate plan for each of your children that has developmental or behavioral needs. This information will be kept confidential.

Today's date

Parents' first and last names

Child's name

Child's age

Please provide a brief description of your child's strengths and interests.

Does your child need 1:1 support?

Yes, we will provide 1:1 support via family or friend

Yes, we need PCC to provide 1:1 support

I'm not sure

If you are providing 1:1 support please list the person's name and relationship to the child.

How does your child communicate best?

Verbally

Non-verbally

Depends on the situation

If your child is unable to communicate verbally, please explain how we can best help your child communicate.

For example, using a communication board that allows your child to point to pictures of emotions or needs.

What are some tools that help your child be successful?

Please check all that apply.

Noise-cancelling headphones

Fidget toys

Sensory toys

Quiet music

Coloring

Books for reading

Social stories

Communication board

Other (please list below)

If you selected "other" above please list additional tools for success.

Please describe what a crisis looks and feels like for your child.

What are some early warning signs that your child is in crisis?

Please check all that apply.

Angry/being rude

Crying

Attempting to leave the room

Impulsivity

Fidgeting/stimming

Isolation/withdrawal

Change in communication (talking more or less than usual)

Increased aggression

Yelling

Irritability

Ignoring instructions

Self-harm

Other (please list below)

If you selected "other" above please list additional warning signs of a crisis here.

What events or experiences may trigger a crisis for your child?

Please check all that apply.

Lack of structure

Change in routine

Unfamiliar adults or children

Separation from preferred person or object

Challenging tasks or activities

Being asked to do multiple things

Being told no

Aggression by another child/Another child in crisis

Unexpected change in environment (ie. new room set-up)

Loud noises

Hunger

Being overtired

Uncomfortable clothing

Other (please list below)

If you selected "other" above please list additional triggers of a crisis here.

How can we best support your child during a crisis and help him/her to de-escalate?

Example: listening to music; taken to a quiet room; tearing paper

Does your child have allergies or additional medical needs? If so, what are they?

Please share any additional information you believe will help us meet your child's needs and ensure he/she has a positive experience.

Thank you for completing the Behavioral Support Plan. This information will be used to ensure the safety of your child.

Solve 8 + 1 = ?

Service Information:

Bible Classes: 9:15-10:15am

Worship Service: 10:30am - 11:45am

Perinton Community Church

636 High Street Extension

Fairport, NY 14450

585-223-7494

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