New Pediatric Client Registration Form

New Client Registration

Please fill in the form below.
Client Information

Please answer each question to the best of your knowledge.
Child's Name

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Child's Date of Birth

MonthDayYear
Date of Evaluation

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Referred By:

First NameLast Name
Parent/ Guardian Name

First NameLast Name
Phone number:
Parent Email Address
Primary Language Spoken
Primary Concern for Evaluation

Other
Please list all current diagnoses the child has received:
(ex. Down Syndrome, ADHD, autism spectrum disorder, etc)
Medical History

Please complete each question to the best of your knowledge.
Pediatrician's Name

First NameLast Name
Has the child experienced any of the following medical complications?

Other
Additional Medical History/Symptoms
Is the child currently taking any medication?
If yes, please list it here
Please list any allergies:
(foods, airborne particles, medicines, etc)
Speech- Language History
What is your primary concern regarding the child's speech/language?

Other
If other, please list the concern below.
When did the child say his/her first word?
Approximately how many total words does the child use?
Does the child use any alternative form of communication? Select all that apply

Other
Hearing Health History
Is there any concern about the child's hearing? Please explain, if yes
Does the child use a hearing aid?
Academic History
What school does the child attend?
What grade is the child currently in?
What type of assistance does the child receive in school?
i.e. self-contained class, resource room, IEP or 504 plan etc.
What are your child's favorite songs or types of music?
Are there any musicians in your child's immediate family?
Does your child have access to musical instruments at home?
(piano, guitar, drums, maracas etc)
What reactions do you see in your child when he/she hears music? (select all that apply)

Other
Does the child currently receive other therapies? If so, which ones? In home, clinic, or school setting?
Are there any precautions I should take in working with your child?
(seizures, biting, self-injurious behavior, etc)
Does your child exhibit sensory-seeking behaviors? Please select all that apply

Other
Does your child exhibit sensory-averse behaviors? Please select all that apply

Other
In what format and/or location would you like to receive MT services?
Please list your child's availability/scheduling needs below.
What else would you like to tell me about your child? Unique qualities, special talents, or anything you think I should know!
Should be Empty:

New Client Registration

Client Information

Medical History

Speech- Language History

Hearing Health History

Academic History