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If your child prefers a nick name, what is it? _____________________________
Does your child have any comfort items? _______________________________
What are your child's favorite things to do? ______________________________________________________
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Does your child have difficulties with any of the following? (please write yes or no)
_____ walking _____ talking _____ eating _____ toileting _____ separation
If you answered "yes" above, please explain:
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What are your child's favorite snacks? __________________________________________________________
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What are your child's food dislikes? ____________________________________________________________
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Is there any medical information or allergies? _____________________________________________________
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Is there any other information you would like us to know about your child? ______________________________
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