NWPT Child Intake Form

Intake Questionnaire
Child's Name

First NameLast Name
Nickname:
Date of Birth:
Age:
Gender:

Other
Diagnosis (if known):
Name of Parent / Guardian #1:

First NameLast Name
Phone Number #1

Area CodePhone Number
Phone #1 Type:
Email
example@example.com
Would you like to receive appointment reminders?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent / Guardian #2:

First NameLast Name
Phone Number #2

Area CodePhone Number
Phone #2 Type:
(OPTIONAL) Parent special circumstances?
Foster parents, shared custody (2nd address), etc.
Emergency Contact Name:
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Relationship to Child:
Child’s Physician:
Physician Phone Number:
Physician Address:
Other Physicians / Specialists Involved In Care:
How did you hear about Northwest Pediatric Therapy?
How do you wish to pay for therapy?
Name of Insurer:
Insurer Policy Number
Picture of your insurance card

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Concerns:
Describe in your own words the nature of your concerns about the child's development and/or the primary referral reasons:
At what age did you first notice the problem?
What are you expecting out this evaluation/meeting?
Social History
Parent 1 Name

First NameLast Name
Parent 1 Age:
Parent 1 Occupation:
Parent 1 Highest Education
Parent 2 Name:
Parent 2 Age:
Parent 2 Occupation:
Parent 2 Highest Education
Marital Status:
What adults live with the child? Check all that apply:
Please list the names and ages of any sibling(s) living in the home.
Is there another language besides English spoken in the home? If yes, please describe the child’s use/understanding of the language(s).
Describe any significant events or changes in the home?
Is there anything additional you would like to share about the family / home environment?
How does the child interact with the following; parents/siblings, other family members, other children:
Does the child become frustrated with certain activities? If yes, please describe:
Is there a family history significant for speech, hearing, feeding, learning emotional, or physical impairment? If yes, please describe:
Birth History
Check any of the following that were relevant to the pregnancy/labor.
If you checked any of the above, please describe.
What was the child's weight in lbs and oz?
How many weeks gestation was the child born?
Location of delivery:   Hospital   Birthing Center   Home
How was the child delivered?
Cesarean section: Scheduled   Emergency
Vaginally:   Unassisted   Assisted
Mothers age at the time of delivery:
Please describe any complications or interventions during delivery, if applicable:
How was the child fed Breast Bottle How long?

Describe any abnormalities in crying, sucking, breathing or weight gain:
Medical History
Does the child have a history of any of the following? Check all that apply.

Other
If you checked any of the above please describe (Age at diagnosis, severity etc.):
Describe any other pertinent information about the child's medical history (surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom:
Is the child up to date with immunizations
If no, please describe:
Has the child ever had surgery?
If yes, please explain:
Has the child ever been hospitalized:
If yes, please explain:
Is the child currently on any prescription medications?
If so, please list prescription medication name and reason for medication:
Is the child currently on any over-the-counter medications?
If so, please list over-the-counter medication name and reason for medication:
Does the child have any known allergies?
If yes, please list allergies:
Does the child currently use any equipment? (communication device, walker, etc.)
If yes, please describe:
Has the child passed a recent vision screening?
If you have any concerns about the child's vision, please describe:
Has the child passed a recent hearing screening?
If there is a history of ear infections, or any other concerns with the child's hearing, please describe:
Please check if the child previous had, or is currently receiving any of the following:
If yes, please list the person or facilities name, current therapies, and/or last date of service, and reason for leaving if applicable:
DEVELOPMENTAL HISTORY
Does or did the child have any of the following (check all that apply):
Colic Feeding problems Sleeping Problems
If you checked yes for any of the above, please describe:
To the best of your knowledge, at what age did the child do the following:
Sit alone:
Crawl:
Stand:
Walk:
Babble:
Say first word:
Say 1-2 words phrases:
Speak in sentences:
Feed self:
Toilet trained:
Dress self:
Wean from bottle/breast
Eat solid foods
Does the child do any of the following?
If you checked any of the above, please describe:
Speech and Language History
If under 4 years of age, how many words does the child say:
Does the child produce sentences of the following length:
What percentage of the child’s speech do you understand?
How well do people outside of the family understand the child's speech (unfamiliar listeners)?
Does the child use other methods of communication (sign language, gestures, etc.)? If yes, please describe:
Does the child avoid speaking?
Yes   No
Does the child recognize his/her difficulty?
Yes   No
Does the child become frustrated by communication difficulties?
Yes   No
How do the child’s communication difficulties impact the family?
Please provide examples of the child's present speech and language skills and their ability to follow directions:
Sensory Motor History
Do you have any concern about the child’s sensory development? If yes, please describe:
Please check any of the following areas that apply to the child:
Gross Motor History
Do you have any concern about the child’s motor development? If yes, please describe:
Please check any of the following that apply to your child:
Academic History
Is the child enrolled in school or daycare? Where? What grade?
Does the child have an IEP/504
Please check any that apply to the child:
What are the child’s favorite activities?
What are your goals for the child over the next 6 months?
What are your goals for the child over the next 5 years?
Person filling out the form?
Relationship to the child?
Should be Empty:

Intake Questionnaire

Concerns:

Social History

Birth History

Medical History

DEVELOPMENTAL HISTORY

Speech and Language History

Sensory Motor History

Gross Motor History

Academic History