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PATCH Adaptive Care Plan Questionnaire: Community Resource Version

The PATCH Program was initially established to serve patients and their families who receive care at Children’s. And true to Children’s Mission to improve the life of every child, it was also created to be shared with others.

To that end, we have created a self-guided version of our adaptive care plan questionnaire that parents can fill out and use as a tool to communicate with their child’s care providers anywhere, so that if your child is not a Children’s patient, you can still benefit from PATCH. Use our printable questionnaire to create a personal adaptive care plan that you can save and share with your child’s care team. This plan is for your use only and does not become part of your child’s medical record.

To create your child’s personal adaptive care plan:

  • Open the link on a computer to access the questionnaire — we do not recommend using a mobile device. A questionnaire in PDF form will open.
  • You have two options for completing the form:
    1. You can complete the form by typing directly into the PDF. Click “save” or “print” when you’re done. If you have the option to save or print it with or without your changes, make sure to choose “with changes.”
    2. Print the form and fill it out by hand.
  • Keep a copy of the form on file so that you can easily access it and make changes as necessary.

PATCH Adaptive Care Plan Questionnaire – Community Resource Version

Download PDF

You can share the document with your members of your child’s care team as you deem appropriate and request that they review it before approaching or administering care to your child — so that they have a better understanding of your child’s communication needs, sensory differences, and coping suggestions.

This questionnaire is not intended to provide, and does not constitute, medical advice. The information stated herein is general in nature and is not a substitute for consultation with a medical professional. Children’s Nebraska (“Children’s) is not seeking to create any kind of provider or physician-patient relationship by providing access to this form; and neither Children’s, nor its affiliated entities, employees, directors, physicians employed by Children’s or its affiliated entities, or any other representative of Children’s or its affiliated entities represents or warrants that use of this form is medically appropriate. Any questions related to the information set forth herein should be addressed to your or your child/ward’s physician.”


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