NEW CLIENT INTAKE QUESTIONNAIRE / CUESTIONARIO DE ADMISIÓN DE NUEVOS CLIENTES
CHILD'S IDENTIFYING INFORMATION / INFORMACIÓN DE IDENTIFICACIÓN DEL NIÑO
CHILD'S NAME / EL NOMBRE DEL NIÑO
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First Name
Last Name
CHILD'S DATE OF BIRTH / FECHA DE NACIMIENTO DEL NIÑO
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Month
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Day
Year
Date
PARENT/GUARDIAN/CAREGIVER CONTACT INFORMATION / INFORMACIÓN DE CONTACTO DEL PADRE/TUTOR/CUIDADOR
Name / Nombre
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First Name
Last Name
Relationship to Child / Relacion hacía el niño
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Address / Dirección
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number / Número Celular
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This number must be a cell phone number as it will be used to send appointment reminders. / Este número debe ser un número de teléfono celular, ya que se utilizará para enviar recordatorios de citas.
Home Phone Number/Landline / Número de teléfono de casa/línea fija
Please enter a valid phone number. / Por favor ingrese un número de teléfono válido.
Email / Correo electrónico
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A copy of this release will be emailed to you. If you do not have an email address, please enter admin@asapdevelopment.org and a copy will be mailed to your address on file. Thank you. / Se le enviará por correo electrónico una copia de este comunicado. Si no tiene una dirección de correo electrónico, ingrese admin@asapdevelopment.org y se le enviará una copia a su dirección registrada. Gracias.
FAMILY INFORMATION / INFORMACIÓN FAMILIAR
List names and ages of children in the family: / Enumere los nombres y las edades de los niños de la familia:
Please leave blank if not applicable. / Por favor, déjelo en blanco si no corresponde.
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REFERRAL INFORMATION / INFORMACIÓN REFERENCIAL
Who were you referred by? / ¿Por quién fuiste referido?
San Gabriel/Pomona Regional Center
Other
If you selected "Other," please explain. Options include: Private Insurance (Indicate which provider); Private Pay; Doctor Referral (Indicate Doctor's Name) / Si seleccionó "Otro", explique. Las opciones incluyen: Seguro privado (Indique qué proveedor); pago privado; Referencia médica (Indique el nombre del médico)
What are your concerns for your child? When did you first notice your child's difficulties and how were they apparent to you? / ¿Cuáles son sus preocupaciones por su hijo? ¿Cuándo notó por primera vez las dificultades de su hijo y cómo fueron evidentes para usted?
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What are your child's joys? What are your child's fears/concerns? What are your child's strengths? / ¿Cuáles son las alegrías de tu hijo? ¿Cuáles son los temores/preocupaciones de su hijo? ¿Cuáles son las fortalezas de su hijo?
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DIAGNOSIS / DIAGNÓSTICO
If there are none, please skip this section. / Si no hay ninguno, omita esta sección.
Diagnosis / Diagnóstico
Date of Diagnosis / Fecha de Diagnóstico
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Month
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Day
Year
Date / Fecha
Diagnosed By: / Diagnosticado por:
Physicians/Medical Professional's Name / Nombre del médico/profesional médico
Add any other additional information relating Diagnosis here: / Agregue cualquier otra información adicional relacionada con el Diagnóstico aquí:
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PHYSICIAN / MÉDICO
Physician's Name / Nombre del médico
Specialty / Especialidad
Phone Number / Número de teléfono
Please enter a valid phone number. / Por favor ingrese un número de teléfono válido.
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PRENATAL AND BIRTH HISTORY / HISTORIA PRENATAL Y DE NACIMIENTO
Mother's Age at Birth of Child / Edad de la madre al nacer el niño
If unknown, leave blank. / Si no lo sabe, déjelo en blanco.
Father's Age at Birth of Child / Edad del padre al nacer el niño
If unknown, leave blank. / Si no lo sabe, déjelo en blanco.
Was the mother ill during pregnancy? If yes, please explain and give prenatal months: / ¿La madre estuvo enferma durante el embarazo? En caso afirmativo, explique y proporcione los meses prenatales:
ANSWER ALL THE FOLLOWING THAT APPLY TO THE MOTHER / RESPONDA TODAS LAS SIGUIENTES QUE APLICAN A LA MADRE
PROLONGED LABOR / PARTO PROLONGADO
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YES / SI
NO / NO
If "yes" to prolonged labor, what was the length? / Si respondió "sí" al parto prolongado, ¿cuál fue la duración?
MEDICATION DURING LABOR? / ¿MEDICAMENTO DURANTE EL PARTO?
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YES / SI
NO / NO
If "yes" to medication during labor, what medications were given and for what reason? / Si respondió "sí" a la medicación durante el trabajo de parto, ¿qué medicamentos se administraron y por qué razón?
BIRTH TYPE / TIPO DE NACIMIENTO
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Vaginal Birth / Parto vaginal
Emergency C-Section / Cesárea de emergencia
Planned C-Section / Cesárea planificada
If you answered "Emergency C-Section," what was the reason/complication? / Sí respondió "Cesárea de emergencia", ¿cuál fue el motivo o la complicación?
PREGNANCY TERM / PLAZO DE EMBARAZO
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Full Term (Full Term is considered 37 weeks) / Término completo (Término completo se considera 37 semanas)
Premature / Prematuro
If you answered "premature," at how many weeks was the baby born? / Sí respondió "prematuro", ¿a cuántas semanas nació el bebé?
How many days was the parent's stay in the hospital? / ¿Cuántos días estuvieron los padres de familia en el hospital?
What was the baby's birth weight (if known)? / ¿Cuál fue el peso del bebé al nacer (si se sabe)?
In pounds (lbs) and ounces (oz). / En libras (lbs) y onzas (oz).
What was the baby's birth length (if known)? / ¿Cuál fue la longitud del bebé al nacer (si se sabe)?
In inches
What was the baby's APGAR score (if known)? / ¿Cuál fue la puntuación APGAR del bebé (si se conoce)?
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NEONATAL HEALTH / SALUD NEONATAL
How long was your child's hospital stay? / ¿Cuánto tiempo estuvo su hijo en el hospital?
Was your child diagnosed with Jaundice? / ¿Su hijo fue diagnosticado con ictericia?
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YES
NO
Was your child given a transfusion? / ¿Su hijo recibió una transfusión?
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YES
NO
Was there hemorrhaging? / ¿Hubo hemorragia?
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YES
NO
Were there any feeding difficulties? / ¿Hubo alguna dificultad de alimentación?
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YES
NO
Was your child intubated? / ¿Su hijo fue intubado?
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YES
NO
Was your child diagnosed with retinopathy (ROP)? / ¿Su hijo fue diagnosticado con retinopatía (ROP)?
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YES
NO
Did your child have difficulty breathing? / ¿Tu hijo tenía dificultad para respirar?
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YES
NO
Was your child admitted to the NICU? / ¿Fue admitido su hijo en la UCIN?
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YES
NO
If you answered "YES" to any of the questions above, please explain them here. You can also add additional information here. / Si respondió "SÍ" a alguna de las preguntas anteriores, explíquelas aquí. También puede agregar información adicional aquí.
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DEVELOPMENTAL HISTORY
Check behaviors which you describe your child as an infant:
Cried a lot; fussy; irritable
Non-demanding
Alert
Liked being held
Tense when held
Floppy when held
Resisted being held
Very active
Quiet or passive
Irregular sleep patterns
Happy/content
Drooled excessively
Is your child able to:
Bottle feed
Breast feed
Roll over
Sit unsupported
Crawl
Cruise
Walk
Speak Simple words
Speak in sentences
Potty-trained
If you checked any of the boxes above, at what age was your child for each actvity?
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MEDICAL HISTORY
Allergies? If there are none, please indicate NONE. Do not leave blank!
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Does your child take any medications? If yes, which ones and what is the reason for taking them?
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ADAPTIVE EQUIPMENT
Does your child use any of the following?
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Adaptive stroller
Adaptive toilet chair
Apnea monitor
Heart monitor
Tube fed
Adaptive chair
Supplemental Oxygen
Wheelchair
Adaptive bath chair
Stander
Walker
Gait trainer
Arm/hand braces
Leg/foot braces
PECS
Communication device
NONE
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Pre-Test
Please choose the best answer
By the age of one year old, a child should use their thumb and finger in a pincer grasp to eat finger food.
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True
False
Words like “mama” or “dada” should be heard before the age of one.
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True
False
At the age of two years old a child should be able to kick a ball and walk up and down stairs.
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True
False
By the age of two years old a child should be able to remove and put on simple clothing.
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True
False
Before the age of two a child should enjoy playing make-believe or “imaginary play”.
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True
False
A child should make eye contact and interact with other people outside of their family after they turn three years old.
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True
False
By two years old a child can follow two step directions, such as “Pick up your toy and bring it to me”.
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True
False
A child should be showing interest in using the toilet before they turn three years old.
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True
False
Before a child turns two years old they should be
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Babbling without words
Running and kicking a ball forward
Following two-step directions
Crawling and not walking yet
By 18 months old a child can
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Use furniture to pull to stand and to "cruise"
String two words together such as, "give me"
Sip liquid using a straw
Chew textured food
If a child gets messy while trying to independently eat their meal with their spoon you should
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Take the spoon away
Let them eat with their hands
Allow them to keep practicing with the spoon regardless of the mess
None of the above
If a child cannot listen to an entire story by the age of two years old, there may be a delay in their
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Adaptive skills
Cognitive skills
Gross motor skills
None of the above
By 12 months old a child should
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Remove their socks and shoes
Put on their socks and shoes
Unbutton their pants
None of the above
If a child cannot hold their crayon or pencil correctly by the age of three years old, there may be a delay in their
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Cognitive skills
Fine motor skills
Gross motor skills
Social skills
Children start expressing feelings such as anger, tiredness, excitement and hunger
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After a year old
After two years old
At six months old
Before three months old
Children will start showing preference for certain toys or activities
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At the age of one
At the age of two
At the age of three
At six months old
If a child does not like their hands to be messy you should
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Always clean their hands the second they get dirty
Introduce them to different textures
Interact with them by doing “messy play” (i.e. playing with paint, soap, play-doh)
Let them get upset and leave their hands dirty
If a child does not crawl before they turn a year old there may be a delay in their
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Cognitive skills
Fine motor skills
Gross motor skills
Social skills
Are there any community resources available in your area? If so, please list them. Where could you look or inquire about community resources?
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What kind of community resources would be beneficial for you and your child? Are there any particular community resources you would be interested in learning more about? If so, please list them.
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This form was completed by:
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First Name
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Relationship to Child
Parent/Guardian/Legal Representative of Child Signature
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