Main Office:
9129 Monroe Road, Suite 100-105
Charlotte, NC 28270
Fax: 704-847-2033
Email: info@crosswaytherapy.com
Phone: 704-847-3911
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Birth to 3 Years
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Client Case History
Date
*
Child's Name
*
First
Last
Parents/Guardian
*
First
Last
Mobile Phone Number
*
Email
*
Work Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
2nd Contact Parent/Guardian
*
First
Last
[object Object]
Mobile Phone Number
*
Work Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Father's Employer:
*
Mother's Employer
*
Insured's Name
*
Insurance Company
*
Policy Number
*
Group Number
*
Insured's Social Security Number
*
Client's Social Security Number
*
Referred by
*
Primary Physician
*
Medical History
Please explain further any checked above or if a condition is not listed that you feel is important please describe:
Was prenatal care initiated? If so, at what month?
*
How long was the pregnancy?
*
Was there any illness or accidents during pregnancy?
*
How long was the labor?
*
How long was the child hospitalized after birth?
*
Was an epidural used?
*
Is your child adopted?
*
Does your child know that he or she is adopted?
*
At what age was he or she adopted?
*
Was your child breastfed or bottled-fed?
*
Choose Any
*
Adenoidenectlomy
Allergies
Anoxia
Asthma
Blood Disease
Chicken Pox
Cyanosis
Croup
Feeding tubes
Frequent colds
Dental problems
Diphtheria
Drooling
Ear infections
Encephalitis
Head Injuries
Hearing Impairment
High Fevers
Hospitalization
Influenza
Jaundice
Measles
Meningitis
Mouth breather
Mumps
Muscle disorder
Nerve disorder
PE Tubes
Plagiocephaly
Pneumonia
Rheumatic fever
Seizures
Tonsillectomy
Torticollis
Vision impairment
Please explain further any checked above or if a condition is not listed that you feel is important please describe:
*
Describe any major accidents or hospitalization
*
Does your child have any medical diagnoses (ADD, Autism, Dyslexia, Hearing/Vision Impairment, etc)? If yes, at what age was he or she diagnoised?
*
Is your child taking any medication? If yes, please list the dosage, frequency and the condition that is being treated.
*
Please list the professionals that your child has seen with contact information
Psychologist
*
Phone Number
*
Neurologist
*
Phone Number
*
Occupational Therapist
*
Phone Number
*
Allergy Specialist
*
Phone Number
*
Social Worker
*
Phone Number
*
Speech Therapist
*
Phone Number
*
Sleep Specialist
*
Phone Number
*
Educational Specialist
*
Phone Number
*
Developmental Optometrist or Ophthalmologist
*
Phone Number
*
Psychiatrist
*
Other
*
Phone Number
*
Phone Number
*
School History
Name of School
*
Teacher
*
Grade
*
Teacher
*
Grade
*
Developmental History
Motor Development
Please indicate your child's age when they first began the following:
Sat up alone
*
Pulled self to standing
*
Crawled
*
Walked
*
Rode tricycle
*
Used Utensils to feed self
*
Tied Shoes
*
Rode bycycle
*
Undressed self
*
Reached for a toy
*
Dressed self
*
Finger fed
*
Buttoned/Zippered
*
Self-Care
Please describe the level of assistance that you provide with the following self-care activities with 1 being the "least"(the chords independent) to 5 being the "most"
Tooth brushing
*
Hair Washing
*
Bathing
*
Dressing
*
Haircuts
*
Sits for meals
*
Keeps tracks of own belongings
*
Organizes homework
*
Transitions easily
*
Toileting skills
*
Arousal/Attention/Self-Regulation:
Yes or No?
Is an early morning riser
*
Yes
No
Awakens during the night
*
Yes
No
Select One
*
Option 1
Option 2
Option 3
Submit
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