TVTP Intake form

Name
Date

MonthDayYear
Date
Date of birth

MonthDayYear
Date
Age
Sex
Languages spoken in the home

Other
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
Problems during

Other
Labor
Nursery
Length of time in nursery
Delivery
If Cesarean, why?
Problems in the hospital nursery
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
Format: (000) 000-0000.
Address
Email
example@example.com
Is your child being followed by any of the following specialists?
Please give details for those checked including names, dates, concerns, and recommended interventions
Has your child had any of the
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
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?
If yes, please list medications and why they have been prescribed.
Sleep/ Appetite
Which of the following apply

Other
What time does your child go to sleep each night? Wake up?
Which of the following apply regarding your child’s feeding/appetite?

Other
Does your child frequently experience any of the following?
Hearing/Vision
Has your child had a hearing test?
If yes, what was result?
Do you have concerns about your child's hearing?
Has your child had a vision test?
If yes, what was result?
Do you have concerns about your child's vision?
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?

Other
How many words does your child currently have in their vocabulary?
Has your child had any regression in their language skills?
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.

Rows	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?
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)?
Has your child received any of the following PRIVATELY (outside of school) in the past??
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)?
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!