• Be Kind Form

  • Be Kind Caregiver Form for

  • e.g. closest or name specific hospital near school
  • Drug NameMilligramsDoseWhen givenPharmacy 
  • Supplement NameAmountWhen givenUsed for 
  • About Me

  • Safety Concerns

  • e.g. hits head, will bite others, runs into traffic
  • e.g. enjoys helping, interrupts, ignores, aggressive
  • e.g. wants to be included, indifferent, aggressive, fearful, overly trusting
  • Eating

  • Hygiene assistance

  • Full assistance neededSome assistance neededCompletely Independent
    Toileting assistance
    Female menaces assistance
    Dressing appropriately for the weather
    Eating assistance
    Drinking assistance
  • Preferences

  • Behaviors

  • e.g. rocking, swinging, playing with fidget device, bouncing on a therapy ball, special chairs, quiet room, dark room, headphones
  • e.g. screen time, videos, music, food reinforcer, outside breaks, toys
  • e.g. wait 10 seconds for an answer, prompt with the first syllable of the word, ask to point
  • e.g. rocking chair, swing, quiet room, headphones
  • This field is for validation purposes and should be left unchanged.