SECTION 1 - PERSONAL INFORMATION
Person Completing This Form
Are You The Primary Contact?
YES NO
Primary Contact Email
Primary Contact Phone
Parent 1 Name
Parent 1 Age
City
Parent 1 Address
State
Zip
Parent 1 Employer
Parent 1 Occupation
Parent 1 Education Completed
Grade School High School Graduate Post Graduate
Parent 2 Name
Parent 2 Age
Parent 2 Address (If different from above)
State
City
Parent 2 Employer
Zip
Parent 2 Occupation
Parent 2 Education Completed
Grade School High School Graduate Post Graduate
Are Other Children In The Household (Please List)
If yes, please describe
Who referred you for the treatment / evaluation?
Self-Referral Doctor School Other Therapist
Referring Doctor / Specialist
Contact Phone
Child’s pediatrician or family doctor
Please attach any previous evalutations or medical records:
Contact Phone
Address
If yes, name of agency
Date Tested
* Please request that copies of all test results be sent to our office
PRIMARY INSURANCE CARD (FRONT)
SECTION 2 - INSURANCE INFORMATION
PRIMARY INSURANCE CARD (BACK)
SECONDARY INSURANCE CARD (FRONT)
SECONDARY INSURANCE CARD (BACK)
Please upload a copy of your insurance card(s).
Primary Insurance
Policy Holder Name
Policy Holder Date of Birth
Member ID Number
Phone Number
Group Number
Secondary Insurance
Policy Holder Name
Policy Holder Date of Birth
Member ID Number
Group Number
Phone Number
SECTION 3 - PATIENT INFORMATION
Patient Name
Patient Date of Birth
SECTION 4 - CHIEF COMPLAINT
Why are you bringing your child to see us today?
SECTION 5 - GESTATIONAL / BIRTH HISTORY
Type of birth:
Normal Induced Forceps Caesarean Premature
How many weeks
Child's Birthweight
If yes, please describe:
SECTION 6 - MEDICAL HISTORY
Give ages of development for the following behaviors:
Sitting unsupported
Eating solid foods
Crawling
Standing alone
Walking
Self feeding
Self dressing
Bladder/bowel control
Date and type of last medical examination
Type of last medical examination
Date
Known diagnoses (and date if known)
List ages for any of the following childhood diseases:
Whooping cough
Mumps
Measles
Rheumatic fever
Pneumonia
Other
Chicken Pox
Tonsillitis
If yes, please describe:
If yes, please describe:
If yes, please describe:
Hearing Test Results
If yes, when?
If yes, when?
If yes, please describe:
If yes, please describe:
If yes, please describe:
SECTION 7 - MEDICATION
List all medications your child is currently taking
SECTION 8 - SURGICAL HISTORY
If yes, please list each procedure, the date the procedure was performed and any complications:
SECTION 9 - FEEDING HISTORY
If yes, please describe:
If yes, please describe:
SECTION 10 - TREATMENT HISTORY
If Yes, please provide the name, contact information and agency of the child’s current therapist.
When
Name of the Agency
SECTION 11 - CURRENT LEVEL OF COMMUNICATIVE FUNCTION
List sounds or words that the child has trouble saying:
How does the child compare with siblings in speech development?
Give examples of sentences the child uses by himself/herself (not sentences that are repeated after you):
Does the child prefer to use speech or gestures when communicating?
SECTION 12 - PRIOR LEVEL OF COMMUNICATIVE FUNCTION
At what age did the child:
babble
say first words
say two word sentences
Current School
say three word sentences
SECTION 13 - EDUCATION HISTORY / SCHOOL PERFORMANCE
Grade
Address
City
State
ZIP
If yes, when? What ages?
At what age did the child attend kindergarten?
Describe performance in school (please note strong and weak areas):
If yes, please describe:
SECTION 14 - DAILY BEHAVIOR / MENTAL COGNITIVE FUNCTIONING
What are your most frequent discipline problems with this child?
Who does the disciplining?
How do you discipline?
What does the child do well?
What does the child have trouble doing?
SECTION 15 - CONTACT OPTIONS / AUTHORIZATION
Submit Information
