"*" indicates required fields

Child's Name*
Child's Date of Birth*
Child's Current Age

Based on date of birth entered.
Sex
Child's Home Address
What is your preferred method of contact?
Caregiver Information*
*Please list ALL parents/legal guardians*
First Name
Last Name
Relationship to Child
 
Siblings Living in Home
Name
Age
 
Language(s) Spoken in Home*
Has your child's pediatrician provided you with:*
Max. file size: 50 MB.
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Insurance

Insurance Information

Policy Holder's Name*
Policy Holder's Date of Birth*
Max. file size: 50 MB.
Max. file size: 50 MB.

Medical History

Do you have any concerns with your child’s hearing?*
Do you have any concerns with your child’s vision?*
Does your child have any feeding difficulties/concerns?*
Does your child have any of the following medical conditions?
Has your child had any major hospitalizations?*
Does your child take any medications?*
Medications*
Medication Name
Dosage/Frequency Taken
 

Birth History

Type of Birth*
Select any of the following complications:

Developmental History

Please describe your child's gross motor skills:*
Ability to walk, climb, jump, etc.
Please describe your child's fine motor skills:*
Ability to grasp/hold a writing instrument, the pincher reflex, for example holding a Cheerio

Therapy History

Does your child have a current or past diagnosis?*
Examples: Autism Spectrum Disorder, ADHD, Epilepsy, etc.
Child's Past or Current Therapies

Occupational Therapy

Speech Therapy

Physical Therapy

Development Therapy

Social Work

Psychology

ABA

Other

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Feeding

Speech/Language Background Information

Is there a family history of speech and/or language difficulties?*
Please select your child's main form of communication:*
What percentage of the time are you able to understand what your child is saying?*
What percentage of the time is an unfamiliar listener able to understand what your child is saying?*
Do you have any concerns about your child’s ability to follow directions?*
Is your child aware of their speech/language difficulties?*

Feeding Background Information

Please select all of the following that apply to your child:
Did your child experience any challenges with breastfeeding?*
Did your child experience any challenges with bottle feeding?*
Did your child experience any challenges when transitioning to purees?*
Did your child experience any challenges when transitioning to table foods?*
Does your child experience any of the following before, during, or after feedings?
Are there distractions during mealtimes?*
Did your child take a pacifier?*
Does your child refuse foods from any of the following food groups? (Check all that apply)*
Please indicate all of your child’s food preferences. (Check all that apply)*
Please indicate your child’s primary method of feeding themselves. (Check all that apply)*
Please indicate your child’s drinking abilities. (Check all that apply)*
When is your child’s appetite best?*
Does your child appear to have sensitivities to any of the following:
Does your child mouth, chew on, or bite clothing and objects?*

Daycare/School

Does your child attend daycare/camp?*
Days/Week
Does your child attend school?*
Does your child have an IEP or 504 plan in place at school?*
Please describe your child's play skills:*
Does your child participate in any play groups?*

Other

Consent

Parent/Legal Guardian*
MM slash DD slash YYYY
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