C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-22. Parent / Sibling Exposure parents have no parents have no parents have no One or both of the Child’s Child’s Child’s child’s developmental disabilities. developmental disabilities. developmental disabilities. parents have been diagnosed The child has no siblings or Child has siblings who are Child has a sibling who is with a developmental existing siblings are not experiencing some mild experiencing a significant disability, or the child has experiencing any developmental or behavioral developmental or behavioral multiple siblings who are developmental or behavioral problems. problem. experiencing significant problems or this information developmental or behavioral is unknown to me. problems. If the needs / functioning fall within a shaded box, explain why: child’s D. ADDITIONAL DETAILS OF OF NEED (OPTIONAL) CHILD’S LEVEL Attach school, medical, psychological or other evaluations that document the current special care needs and / or attach child’s of signed ‘Confirmation Needs’ forms. SECTION III. AUTHORIZATION
C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-22. Parent / Sibling Exposure Child’s parents have no developmental disabilities. The child has no siblings or existing siblings are not experiencing any developmental or behavioral problems or this information is unknown to me. Child’s parents have no developmental disabilities. Child has siblings who are experiencing some mild developmental or behavioral problems. Child’s parents have no developmental disabilities. Child has a sibling who is experiencing a significant developmental or behavioral problem. One or both of the child’s parents have been diagnosed with a developmental disability, or the child has multiple siblings who are experiencing significant developmental or behavioral problems. If the child’s needs / functioning fall within a shaded box, explain why: D. ADDITIONAL DETAILS OF CHILD’S LEVEL OF NEED (OPTIONAL) Attach school, medical, psychological or other evaluations that document the child’s current special care needs and / or attach signed ‘Confirmation of Needs’ forms. SECTION III. AUTHORIZATION
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