New Patient Intake Form Contact InformationParent / Legal Guardian Name* First Last Phone*Email* Patient InformationName* First Last Date of Birth MM slash DD slash YYYY Gender Male Female Child lives with both parents? Yes No Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country School or Daycare (please include school, grade and teacher)What is your chief concern about your child?Insurance InformationInsurance Provider Policy Holder Name First Last Relationship to Policy Holder Policy Number Group Number Medical InformationPediatrician Current Medications Any diagnoses Are immunizations current? If no, please explain AllergiesPrevious hospitalizations/surgeries (please include reason, dates, and length of stay)Other doctors (dentists/psychologists/specialists) that provide care to this childPrevious therapy history (please include how long and by whom)Any hearing or vision difficulties (tubes, ear infections, etc)Prenatal/Birth HistoryFull term Yes No Birth Weight Delivery Type Vaginal Cesarean Breech Feet First If no, how many weeks? Illnesses or accidents during pregnancy Medications used during pregnancy Length of Labor Was labor induced or spontaneous Any fetal distress, oxygen required, etc Did your child require NICU care? If so, how long? Developmental HistoryPlease indicate the age when your child did the following (If you cannot remember exactly, indicate if it was expected or delayed) Sat up alone Crawled Walked Make wants/needs known Eat pureed fruits/veggies Eat pureed meats Eat raw fruits/veggies Used a straw Used cup without lid Has your child had any feeding difficulties? Please explainDoes your child choke while eating? If yes, on what foods?Is your child a picky eater? If yes, what foods are preferred?Does your child drool excessively? Yes No Have difficulty gaining weight? Yes No Did or does your child suck their thumb or use a pacifier? Speech and Language DevelopmentHow well is your child understood by Primary parent/guardian: Other parent/guardian Unfamiliar Adults Describe what it is like to have a conversation with your childLanguage(s) spoken at home Child’s primary language What age did your child say first words? What age did your child say first phrases? What age did your child say first sentenses? How many words can your child say? Please list if fewer than 15What is the primary method your child uses to communicate wants/needs? Looking at objects Pointing at objects Gestures Crying Vocalizing/grunting Physical manipulation Single words 2-3 word combinations Sentences Does your child have difficulty following directions? Please describe Does your child have difficulty producing certain sounds? If yes, which ones? Which of the following best describes your child’s speech? Easy to understand Difficult for parents to understand Difficult for others to understand Almost never understood by others Which of the following best describes your child’s reaction to his/her speech? Easily frustrated when not understood Doesn’t seem aware Attempts to say sounds/words more clearly when asked Is there a history of speech or language difficulties in the family? Please explain BehaviorDescribe your child’s behavioral characteristics. Check all that apply Cooperative Attentive Withdrawn Stubborn Aggressive Impulsive Inappropriate behaviors Self abusive behavior Poor eye contact Play SkillsDoes your child make friends easily, play well with others? Please describeWhat is the length of time your child can stay playing at one activity? What activity seems to hold your child’s attention for the longest period of time? What activity seems to hold your child’s attention for the shortest period of time? Does your child have tantrums? If yes, please describe Which of the following describes the type of play your child likes to engage in the most often? Putting toys in mouth Banging toys together Throwing toys Shaking toys Pushing/pulling toys Role-playing Acting out familiar routines Games with rules Rough and tumble play Looking at books Self-CarePlease indicate whether your child can do the following independently Take off Socks Take off Shoes Take off Pants Take off Shirt Put on Socks Put on Shoes Put on Pants Put on Shirt Fasten Velcro Fasten Buttons Fasten Zipper Fasten Snaps Fasten Shoes laces (Meals) Finger Feed (Meals) Use fork (Meals) Use spoon (Meals) Use knife (Meals) Drink from cup (Hygiene) Urinate (Hygiene) BMs (Hygiene) Wash hands (Hygiene) Brush teeth (Hygiene) Brush hair (Hygiene) Bathe Please indicate whether your child can do the following with help Take off Socks Take off Shoes Take off Pants Take off Shirt Put on Socks Put on Shoes Put on Pants Put on Shirt Fasten Velcro Fasten Buttons Fasten Zipper Fasten Snaps Fasten Shoes laces (Meals) Finger Feed (Meals) Use fork (Meals) Use spoon (Meals) Use knife (Meals) Drink from cup (Hygiene) Urinate (Hygiene) BMs (Hygiene) Wash hands (Hygiene) Brush teeth (Hygiene) Brush hair (Hygiene) Bathe Sensory ProcessingDoes your child seem over or under sensitive to any of the following? Please describe Sounds Touch Movement Light Pain Temperature Clothing Completed by* First Last Relationship* Date* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
