Special Needs Child Home Environment Report

Child Name Date of Report Completed by

1. Physical Environment

Describe the child's primary living space Accessibility adaptations present Safety features in the home

2. Family & Social Environment

Family members in the home Support systems available (e.g. caregivers, respite)

3. Routines & Activities

Daily routine overview Activities/hobbies the child enjoys Therapies or support services received at home

4. Needs & Suggestions

Identified challenges or areas of concern Recommendations for environmental adaptations or supports