Caregiver

Be Kind Form
Your Name*
First Last
Your Email*
Be Kind Caregiver Form for
Be Kind Caregiver Form for
First Last
Speech Impacted by Autism
- Mild
- Moderate
- Profound
Emergency Contact*
First Last
Emergency Contact Relation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Backup Contact Name and Phone
Hospital of choice in an emergency:
I take medications
- yes, please see my medications form
- no
Medications
Drug Name Milligrams Dose When given Pharmacy
Allergies to medications
I take supplements
- yes, please see my supplements form
- no
Supplements
Supplement Name Amount When given Used for
Safety Concerns
Self-injurious or aggressive behavior
e.g. hits head, will bite others, runs into traffic
Stranger interaction
e.g. aggressive, fearful, overly trusting
Wandering
- I stay by my caregiver’s side
- I sometimes unconsciously wander away
- I intentionally run away
Additional safety comments
Eating
I have food allergies or sensitivities
- yes, please see Food Sensitivity Form
- no
I usually eat at these times:
Favorite Beverages
I need to be prompted to drink
- yes
- no
Grooming
Independence scale for grooming
Full assistance needed Some assistance needed Completely Independent
Brush Teeth
Shower
Pick Out Clothes
Get Dressed
Brush or Comb Hair
Shaving
Female menaces assistance
Clip nails
Lotions or cream application
When choosing an outfit I usually wear:
When clothes are dirty, I place them:
Preferences
Items to Bring on Outing
- Water Bottle
- Food
- Communication Device
- Money
- ID
- Safety Vest
- Medication/Supplements
- Stim toy
- Comfort item
- Safety item
- Tracking device
Other items:
Music I enjoy
Computer programs I enjoy
Television I enjoy
Places I enjoy visiting
Behaviors
The following are triggers for me:
These triggers may invoke the following behaviors:
The following stimming helps me stay regulated:
Untitled
- First Choice
- Second Choice
- Third Choice
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

	Full assistance needed	Some assistance needed	Completely Independent
Brush Teeth
Shower
Pick Out Clothes
Get Dressed
Brush or Comb Hair
Shaving
Female menaces assistance
Clip nails
Lotions or cream application

Drug Name	Milligrams	Dose	When given	Pharmacy

Supplement Name	Amount	When given	Used for

Caregiver

Be Kind Form

Be Kind Caregiver Form for

Safety Concerns

Eating

Grooming

Preferences

Behaviors

Stay In Touch