Student Interest Form

Thank you for your interest in Anchor Academy!

We are a Christ-centered, therapeutic school serving children with high support needs in communication and behavior. Our process begins with this form, followed by a parent conversation to determine if Anchor is a good fit for your child and family.

SECTION 1: Student Information

Child’s Full Name:
Age:

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Current Educational Setting

[ ] Public School
[ ] Private School
[ ] Homeschool
[ ] Full-Time ABA
[ ] Other: </aside>

SECTION 2: Parent / Guardian Information

Parent/Guardian Name(s):
Relationship to Child:
Phone number:
Email:
City/location:

SECTION 3: Communication Profile

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How does your child primarily communicate (select all that apply)?

[ ] Speaking
[ ] Minimally speaking/non-speaking
[ ] Limited/unintelligible speech
[ ] Gestalt language processor (scripts, echolalia, songs)
[ ] AAC/speech generating device
[ ] AAC/low tech (switch, PECS)
[ ] Spelling - letterboard
[ ] Spelling - keyboard
[ ] Gestures/guiding
[ ] Sign language
[ ] Other: </aside>

SECTION 4: Support Needs

What are your child’s greatest areas of need? (examples: communication, behavior, regulation, sensory, transitions, etc.)

Which best describes your child’s support needs?

[ ] Moderate support
[ ] High support
[ ] Very high/constant support