Swim Club Questionnaire | sunmoonandstars

Can your child swim independently?

Yes

No

Can your child go under water or put his/her face in the water?

Yes

No

Is your child safe around water?

Yes

No

Check primary concern

Attracted to water (deep pressure, sensory-seeking, etc.)

Difficulty following commands (Don't run! etc.)

Fear of water (putting face in, deep end, etc.)

Behavior challenges (aggression, elopement, impulsivity, and/or etc.)

Other (please explain in comments box)

Will behavior tech or BCBA support be needed during lessons?

Yes

No

Has the child received a autism diagnosis?

Yes

No