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Camper Pre-Camp Questionnaire
Caregiver’s Name
(Required)
First
Last
Caregiver's Email
(Required)
Caregiver's Phone
(Required)
Camper's Name
(Required)
First
Last
How does your child typically interact with others in a group environment?
(Required)
Friendly & happy to join the group
Interacts well, but takes a while to feel fully comfortable
Often Shy or anxious until gets to know folks
Struggles with group interactions
How does your child typically interact with adult leaders or authority figures?
(Required)
Friendly & happy
Interacts well, but takes a while to feel fully comfortable
Often shy or anxious until gets to know folks
Struggles with adult leader interactions
What times of day are predictably challenging for your child?
(Required)
Getting up in the morning
Moving between activities
Late afternoon
Going to bed in the evenings
Mealtime
Showering/brushing teeth, etc.
What types of situations typically trigger an emotional response in your child? (check all that apply)
(Required)
Being alone
Being in a big group
Noisy enviornments
Being hot/cold
New foods
Losing a game (challenges with cooperative game play)
Putting on lotion/sunscreen
Strong smells
Other
What type of emotional response(s) does your child display? (check all that apply)
(Required)
Verbal aggression (yelling, arguing, etc)
Physical aggression (hitting, biting, kicking, etc)
Crying
Shut down- curl up in ball, stop talking, hide, isolate
Shut down- dissociation (not present, loses time)
Running away
Other
What types of interventions is your child used to doing for themselves at home which they find helpful?
(Required)
Using fidgets
Cold water/ice/temperature change
Distraction/redirection
Journaling or art
Physical touch
Grounding techniques (breathing, counting, physical grounding)
Taking time alone
Taking time with a caring adult
Physical exercises (running, jumping, swinging, etc.)
Somatic exercises (tapping, stretching and movement)
How does your child use these interventions?
(Required)
On their own — they know how to use them
With a reminder from an adult
If an adult does it with them
They don’t like to use them but I can get them to do it if I introduce it indirectly without “telling them” what it is for
What are signs that you see that your child is about to get upset/dysregulated?
(Required)
What are your child's most common coping skills when they are struggling? How can we best support your child if they are having a hard time?
(Required)
What makes your child feel good?
(Required)
What are your child's strengths?
(Required)
In your experience, what is the most effective way for Help One Child Staff and volunteer team to support your child if they get involved in conflict or interpersonal difficulties or become over stimulated?
(Required)
Anything else that you think would help your child have a great camp experience?
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