Today's Date
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Child's Name
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First Name
Last Name
Child's Nickname or Preferred Name
Child's Date of Birth
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Chlld's Preferred Pronouns
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 1 Name
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Parent 1 Email
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Parent 1 Phone
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Parent 1 contact preference to confirm appointments?
Parent 2 Name
Parent 2 Email
Parent 2 Phone
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Parent 2 contact preference to confirm appointments?
Pediatrician Name
Pediatrician Practice
Pediatrician Phone
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Pediatrician Address
Would you like a copy of any written evaluation to be provided to your child's pediatrician?
Does your child have any health issues or allergies we should be aware of?
Please list any concerns or issues you are seeing at home or school.
Therapy Needs (Check all that apply)
Which type of evaluation are you interested in?
Please list any diagnosis your child may currently have:
Is your child currently on an IEP?
Has your child had an evaluation done within the last year?
If yes, which area was your child evaluated in? (Check all that apply)
Check all that apply:
If other, please describe:
Where were they evaluated?
If other, where:
Please list the name of the test(s) given to your child in their last evaluation. These will be found within the first few pages of the report. Please bring us a copy of your child's evaluation and/or IEP if possible.
From whom/where were you referred?
Is your child adopted?
What type of delivery?
Child was born
What type of delivery?
Were there any complications (NICU) or medical problems at birth?
If 'other' please elaborate
Any history of ear infections?
If applicable - most recent hearing evaluation (when & results):
Has your child had any surgeries or hospitalizations? If so please describe.
List any current medications:
Has your child had a neuro-psychological or pediatric developmental evaluation? If so, please describe outcomes of the evaluation.
List all languages your child speaks or is exposed to:
If bilingual, when was your child exposed to English?
If bilingual, any concerns with your child's primary language?
Child's school and grade:
Current educational accommodations:
If 'other' please elaborate:
Has your child ever received special services (e.g., OT, PT, SLP) ? If so, what services/frequency?
What are your main concerns with your child?
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Does your child's teacher have any concerns with your child's development?
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Do you have any feeding or nutrition concerns? If so, please describe.
What are your child's strengths/favorite things (e.g., books; playing with balls)?
Age rolled over:
Age babbled:
Age said first word:
Age combined two words:
Age sat up alone:
Age crawled:
Age walked alone:
Age drank from a cup:
Age drank with a straw (if applicable):
Age first used spoon:
Does your child interact well with others?
Does your child have any trouble making friends?
Does your child have trouble calming themselves when upset?
Please check any of the following that apply to your child.
If 'other' please elaborate
Receptive language (understanding.) Please check all that apply:
Expressive language (use.) Check all that apply:
Child's primary mode of communication:
Approximate number of words:
Social language/ play skills (check all that apply):
Feeding Skills
Signs Of Tactile Dysfunction: Hypersensitivity To Touch (Tactile Defensiveness):
Hyposensitivity To Touch (Under-Responsive):
Poor Tactile Perception And Discrimination:
Vestibular Sense: The vestibular system is the sensory system that responds to motion or change of head position. The receptors for movement are located in the inner ear. They tell the brain what direction the head is moving, the speed of the movement and where we are in space. Signs Of Vestibular Dysfunction:
Hypersensitivity To Movement (Over-Responsive):
Hyposensitivity To Movement (Under-Responsive):
Poor Muscle Tone And/Or Coordination:
Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch,movement, and changes in position in space. Signs Of Proprioceptive Dysfunction:
Sensory Seeking Behaviors:
Difficulty With "Grading Of Movement":
Signs Of Auditory Dysfunction: (no diagnosed hearing problem)
Hypersensitivity To Sounds (Auditory Defensiveness):
Hyposensitivity To Sounds (Under-Registers):
Signs Of Oral Input Dysfunction: Hypersensitivity To Oral Input (Oral Defensiveness):
Hyposensitivity To Oral Input (Under-Registers)
Signs Of Olfactory Dysfunction (Smells): Hypersensitivity To Smells (Over-Responsive):
Hyposensitivity To Smells (Under-Responsive):
Signs Of Visual Input Dysfunction (No Diagnosed Visual Deficit): Hypersensitivity To Visual Input (Over-Responsiveness):
Hyposensitivity To Visual Input:
Auditory-Language Processing Dysfunction:
Emotional Response, Play, And Self-Regulation Dysfunction: Emotional:
Play:
Self-Regulation:
Internal Regulation (The Interoceptive Sense):
Is there any other information you'd like to share with us?
Notice of Privacy Practices
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The privacy of your medical information is important to us. Please review the
Notice on Privacy Practices to understand how we maintain the privacy of your protected health information
BY INPUTTING YOUR NAME AND E-SIGNING BELOW, you agree that you have been made aware and read our Notice on Privacy Practices.
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Today's Date
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