Cove Sibling SurveyPlease enable JavaScript in your browser to complete this form.Profile - Step 1 of 4Thanks for coming back to fill out a another survey. In this sibling survey, tell us about one of your children that does not attend Cove. If you have more than one, repeat the process for additional children. Remember, we will donate $1 per submission.EmailPlease provide again so we can match up all of your families forms.Child's InformationChild's School LevelSelect OneInfant/ToddlerPreschoolEarly Elementary (K-2)Elementary (3-6)Junior High (7-8)High School (9-10)Transitions ProgramAdultDoes this child have sensory sensitivies?YesNoWhen did you first notice sensory sensitivity in your child?InfantToddlerPreschoolKindergartenElementaryJunior HighHigh SchoolWhat were the first clues of sensory sensitivity? (Select all that apply)Didn't like to be dirtyVery little to no awareness of being messyTrouble riding in the car (motion sickness, crying, etc.)Constantly looking to spin or swingConstantly seeking tactile input (fidgeting, pulling hair, biting nails, etc.)Very little to no awareness of tactile input (barely notices touching things, etc.)Didn't like tactile input (doesn't like the feel of grass, carpet, tags, certain types of clothing)Constantly bumping into things, trippingAfraid of things that test your awareness of body in space (going down the stairs, playground equipment, etc.)Seeking pressure in unusual ways (being squished, pressing body against objects, etc.)Avoiding food that smells or looks funnyTook a long time to potty train (seemed to be unable to tell when they had to go potty, over or under sensitive to dirty diapers)OtherTell us about your child's sensory needs. (Select the most common response per system.)Visual (sights)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingSensory seekingSensory avoidingSensory avoidingDepends on the situationDepends on the situationUnaffectedUnaffectedUnsureUnsureAuditory (sounds)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureOlfactory (smell)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureGustatory (taste)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureTactile (touch)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureVestibular (body in space)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureProprioceptive (pressure on joints)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureIntroception (internal)Sensory seekingSensory avoidingDepends on the situationUnaffectedUnsureSensory seekingItem #1 Sensory seekingSensory avoidingItem #1 Sensory avoidingDepends on the situationItem #1 Depends on the situationUnaffectedItem #1 UnaffectedUnsureItem #1 UnsureNextDoes your child participate in any enrichment programs? (Select all that apply.)SportsNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedScoutsNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedArtNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedMusicNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedDanceNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedSocial programsNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedOtherNoAt schoolOutside of school (OS)OS - with supportsOS - special needs focusedNoItem #1 NoAt schoolItem #1 At schoolOutside of school (OS)Item #1 Outside of school (OS)OS - with supportsItem #1 OS - with supportsOS - special needs focusedItem #1 OS - special needs focusedIn general, how successful is your child in participating in enrichment programs?At SchoolVery SuccessfulFairly SuccessfulIt's a StruggleNot at allVery SuccessfulVery SuccessfulFairly SuccessfulFairly SuccessfulIt's a StruggleIt's a StruggleNot at allNot at allOutside of SchoolVery SuccessfulFairly SuccessfulIt's a StruggleNot at allVery SuccessfulItem #3 Very SuccessfulFairly SuccessfulItem #3 Fairly SuccessfulIt's a StruggleItem #3 It's a StruggleNot at allItem #3 Not at allOutside of School - With SupportsVery SuccessfulFairly SuccessfulIt's a StruggleNot at allVery SuccessfulVery SuccessfulFairly SuccessfulFairly SuccessfulIt's a StruggleIt's a StruggleNot at allNot at allOutside of School - Special Needs FocusedVery SuccessfulFairly SuccessfulIt's a StruggleNot at allVery SuccessfulVery SuccessfulFairly SuccessfulFairly SuccessfulIt's a StruggleIt's a StruggleNot at allNot at allFor this child, what's the maximum distance are you willing to travel for...TheropyTo and from schoolIn town (<20 min)Surrounding area (<40 min)Pretty far (< hour)Anywhere! (> hour)To and from schoolItem #3 To and from schoolIn town (<20 min)Item #3 In town (<20 min)Surrounding area (<40 min)Item #3 Surrounding area (<40 min)Pretty far (< hour)Item #3 Pretty far (< hour)Anywhere! (> hour)Item #3 Anywhere! (> hour)PlaydateTo and from schoolIn town (<20 min)Surrounding area (<40 min)Pretty far (< hour)Anywhere! (> hour)To and from schoolItem #3 To and from schoolIn town (<20 min)Item #3 In town (<20 min)Surrounding area (<40 min)Item #3 Surrounding area (<40 min)Pretty far (< hour)Item #3 Pretty far (< hour)Anywhere! (> hour)Item #3 Anywhere! (> hour)Social activityTo and from schoolIn town (<20 min)Surrounding area (<40 min)Pretty far (< hour)Anywhere! (> hour)To and from schoolItem #3 To and from schoolIn town (<20 min)Item #3 In town (<20 min)Surrounding area (<40 min)Item #3 Surrounding area (<40 min)Pretty far (< hour)Item #3 Pretty far (< hour)Anywhere! (> hour)Item #3 Anywhere! (> hour)Extracurricular activityTo and from schoolIn town (<20 min)Surrounding area (<40 min)Pretty far (< hour)Anywhere! (> hour)To and from schoolItem #3 To and from schoolIn town (<20 min)Item #3 In town (<20 min)Surrounding area (<40 min)Item #3 Surrounding area (<40 min)Pretty far (< hour)Item #3 Pretty far (< hour)Anywhere! (> hour)Item #3 Anywhere! (> hour)Activities with sensory interventions in placeTo and from schoolIn town (<20 min)Surrounding area (<40 min)Pretty far (< hour)Anywhere! (> hour)To and from schoolItem #3 To and from schoolIn town (<20 min)Item #3 In town (<20 min)Surrounding area (<40 min)Item #3 Surrounding area (<40 min)Pretty far (< hour)Item #3 Pretty far (< hour)Anywhere! (> hour)Item #3 Anywhere! (> hour)PreviousNextTell us about a social or enrichment experience where your child was successful. What was the experience? What do you think helped make it successful?Which of the following is most helpful in creating a successful outing for your child? Select only one response in each category.Sensory InputsThe environment is built around sensory sensitivitiesCaregiver provides sensory interventionsNot a factor in successIntegration ModelChild participates with other sensory sensitive kidsChild is integrated with all kinds of kidsNot a factor in successOrganization ModelActivity is grouped by age-levelActivity is grouped by skill or comprehension levelNot a factor in successAdult LeaderIs a good temperament match with your childHas been professionally trainedNot a factor in successDo you think the things that help your child be successful are unique to them? YesNoPreviousNextTell us about a social or enrichment experience that was UNSUCCESSFUL. What was the experience? What went wrong? How did your child react?What does it look like when your child is unsuccessful in a social or enrichment activity? (Select all that apply.)He/she is deregulated during the activityHe/she is deregulated for some period of time after the activityHe/she tries to participate, but is unable to successfullyHe/she wants to participate but is left outHe/she refuses to participateAdult guidance is lackingThe adult in charge lacks knowledge of how to successfully helpThe adult in charge is not a good match with my childDo you think the things that impede your child from being fully successful in an enrichment experience are unique to him/her?YesNoWhat could be done to improve a situation that is not going well? (Select all that apply.)Making sensory interventions availableAssign him/her a buddyCreate lower adult to child ratiosCreate more purposeful integrationsMake a quiet space availableFinding the same activity somewhere else more conducive to our needsA different adult leading the activityBy filling out this survey, I agree to the Privacy Policy and Terms of Use.NameSubmit Share Share Tweet Pinterest Email
