TVTP Intake form

Name
Date

MonthDayYear
Date
Date of birth

MonthDayYear
Date
Age
Sex

malefemale
Languages spoken in the home

EnglishSpanishOther
What are your current concerns regarding your child? Click here to enter text.
Pregnancy and Birth History
Child's birth weight
Gestational age at birth
Prenatal care received

none1st trimester2nd trimester3rd trimester
Problems during

bleeding/spottingfeversgestational diabetesinfection: Click here to enter text.high blood pressureprescribed medication:Click here to enter text.alcohol usedrug exposure: Click here to enter text.tobacco useOther
Labor

inducedspontaneous
Nursery

regular nurseryNICU
Length of time in nursery
Delivery

vaginalCesarean
If Cesarean, why?
Problems in the hospital nursery

breathing problemsjaundiceinfection/sepsisfeeding problemslow temperaturehigh blood sugarheart problemsseizureshigh temperatureother: Click here to enter text.
Were there any problems encountered in Labor and Delivery
Were there any difficulties encountered in the first 6 weeks of life? I.e.- feeding, sleeping
Health/ Medical History
Pediatrician
Phone number
Address
Email
example@example.com
Is your child being followed by any of the following specialists?

Developmental PediatricianPediatric NeurologistPsychologistAudiologistDevelopmental OptometristOphthalmologistNutritionistOther
Please give details for those checked including names, dates, concerns, and recommended interventions
Has your child had any of the

accidents or injuries:head injury:lost consciousness:surgery/operation:other hospitalizations:chronic medical condition:ear infections:seizures:
age of onset of seizures (if applicable)
Please elaborate
age at last seizure (if applicable)
current seizure medication (if applicable)
Has your child been prescribed any equipment? i.e. leg brace, splint, lenses
Does your child have allergies

YesNo
If yes describe type and recommended interventions
Has your child been diagnosed with any medical, psychological, or educational condition?
How would you describe your child's current state of health?
Are there any medical precautions we should know about?
Is your child currently taking any medications?

YesNo
If yes, please list medications and why they have been prescribed.
Sleep/ Appetite
Which of the following apply

falls asleep easilydifficulty settling to sleepwakes frequently during the nightwakes easilysnoresOther
What time does your child go to sleep each night? Wake up?
Which of the following apply regarding your child’s feeding/appetite?

picky eaterdifficulty with food texturespoor appetiteOther
Does your child frequently experience any of the following?

acid refluxdiarrheaconstipation
Hearing/Vision
Has your child had a hearing test?

YesNo
If yes, what was result?

passedfailedunable to test
Do you have concerns about your child's hearing?

YesNo
Has your child had a vision test?

YesNo
If yes, what was result?

passedfailedunable to test
Do you have concerns about your child's vision?

YesNo
Family History
Do any immediate family members have significant medical or developmental concerns?
Have there been any major family changes or significant stressors over the last year that might have impacted your child’s development?
Speech/ Language Development
What age did they say their first word?
What word?
What age did they begin using single words meaningfully (i.e., to request)?
What age did your child begin babbling?
What age did they use phrases/short sentences?
How does your child currently communicate?

word approximationssingle wordsshort phrases (2-3 words)phrases (3 - 4 words)Other
How many words does your child currently have in their vocabulary?
Has your child had any regression in their language skills?

yesno
If yes, please explain
Does your child communicate differently in home and at school or other settings
Developmental Milestone

Indicate the age when your child first did each of the following INDEPENDENTLY. If your child has not yet achieved the milestone, write N/A in the age column.

	Age Achieved	Describe quality of SKILL
Smiled
Held held up
Rolled over
Sat unsupported
Crawled
Pulled to stand
Stood alone
Walked
Ran
Reached for an object actively
Transferred object between hands
Ate unaided with a utensil
Undressed Self
Dressed Self
Bladder trained-days
Bladder trained-nights
Bowel trained

Do you have any concerns regarding your child’s motor or self-care development?
Academic Information
Name of school
Grade
Prior Schools
Grades repeated
Has your child ever attended/received any of the following?

Early Intervention ServicesA Special Needs School/ProgramSpecial Education services
Please elaborate. Include age when child began receiving services and the name of the program?
What are your child’s areas of strength?
What areas does your child find challenging?
Do your child's teachers/administrators have concerns with regards to your child's performance at school?
Do you have any concerns regarding your child's performance at school?
Does your child currently receive any of the following PRIVATELY (outside of school)?

speech therapycurrentoccupational therapycurrentphysical therapycounselingDIRFloortimeApplied Behavioral Analysis (ABA)
Has your child received any of the following PRIVATELY (outside of school) in the past??

speech therapycurrentoccupational therapycurrentphysical therapycounselingDIRFloortimeApplied Behavioral Analysis (ABA)
Social/Communication/Behavior
How would you describe your child's play?
What toys/games/activities does your child prefer?
How would you describe your child's overall temperament and mood?
Does your child demonstrate socially expected behavior in all settings? i.e., school, home, playdate, parties, restaurants.
Do any of the following apply to your child (now or in the past)?

speech/language delaypoor eye contactstrong and/or intense interestshas unusual interests (i.e., lights, street signs, train schedules, wires)strong sensory interests and/or aversions i.e., upset by loud noises, haircuts, nail clipping;motor mannerisms (i.e., hand flapping, spinning, toe-walking)not using gestures to communicate (i.e., pointing, waving, blowing kisses)insistence on sameness and/or difficulty with changes in routinessocial differences (i.e., disinterest in peers, inappropriate during social interactions)regression of skills (lost skills they previously had)
If yes, to any of the above, please explain.
Almost done!
How did you hear about The Village Therapy Place?
Is there anything else you would like us to know about your child?
Thank you for filling out this form! This information helps us prepare for a productive start to therapy. We look forward to meeting you and your child!
Should be Empty:

Pregnancy and Birth History

Health/ Medical History

Sleep/ Appetite

Hearing/Vision

Family History

Speech/ Language Development

Developmental Milestone

Academic Information

Social/Communication/Behavior

Almost done!