Client In-Take FormPlease fill out all fields below and we will be in touch shortly. We can't wait to hear from you! Date MM DD YYYY Basic Information Guardian's Name * First Name Last Name Phone Number * (###) ### #### Email * Guardian Occupations * Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY Child's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Family Living with Child * Names & Ages of Siblings Primary Language Spoken in Home Child's Pediatrician Pediatrician's Phone Number * (###) ### #### Referral Source * Background Information Previous Evaluations Past Therapy Received Areas of Concern When was it first noticed? How was it changed? Is your child understood by others? How does your child communicate with others (words, sounds, gestures)? Prenatal/Birth History Full Term? Birth Weight Complications during Birth? Any conditions affecting pregnancy or birth? Medical History History of illnesses? History of ear infections? Allergies? Any accidents or operations? Any medications? Any hearing difficulties? When was your child's last hearing test? Results? Developmental History Please indicate the approximate age of each milestone: Sat Up Crawled Walked Toilet Trained Fed Independently Weaned from Pacifier Said First Words Combining 2-Words Speaking in Sentences What were your child's first words? Developmental History Please indicate any difficulties: Chewing/Swallowing Drinking Drooling Are there any food aversions? Are there any food allergies? Favorite Foods? Educational/Social History Child's Current School & Grade Child's Academic Performance Services Received in School Teacher Concerns Does your child have friends in school? Does your child follow directions? How does your child handle separation? How does your child handle frustration? What motivates your child? Other What do you hope to happen as a result of this evaluation? Any other patient information? Payment Information (Party Responsible for Payment) Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Company Name * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Phone Number * (###) ### #### Client Accountability It is your responsibility to verify your insurance carrier covers this office visit. As a courtesy, we will check benefits, but it is strongly suggested you check as well. You will be responsible for any insurance fees. Call the number provided on your insurance card to verify that we participate in your network. Thank you!
