Client History Form

Client Case History

* Indicates required field

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

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? *

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 *

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 *

Awakens during the night *

Select One *

Submit

​​Client Case History

Medical History

Please list the professionals that your child has seen with contact information

School History

Developmental History

Motor DevelopmentPlease indicate your child's age when they first began the following:

Self-CarePlease 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"

Arousal/Attention/Self-Regulation: Yes or No?

Client Case History

Motor Development
Please indicate your child's age when they first began the following:

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"