Form
Client Demographic Information:
Client Name
*
First Name
Last Name
Client's Date of Birth
*
Client's Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian/Parent Name #1
*
First Name
Last Name
Guardian/Parent Name #2
First Name
Last Name
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Primary Email Address
example@example.com
Insurance Carrier
*
What services are you seeking from Learning Solutions?
Psychological Testing
Applied Behavior Analysis Therapy
Occupational Therapy
Speech Therapy
Other
Emergency Contacts
Emergency Contact #1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to client:
Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to client:
Please list those who are authorized to pick up the client:
Insurance Information:
Primary Insurance Information
Policy Holder's Name
*
First Name
Last Name
Policy Holder's Date of Birth:
*
-
Month
-
Day
Year
Date
Insurance Company:
*
Insurance ID#:
*
Insurance Group#:
Employer:
Please upload a picture of the front and back of your insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance
If applicable
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Insurance Company:
Insurance ID#:
Insurance Group#:
Employer:
Please upload a picture of the front and back of your insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Family Information
Please list any legal or custody information we need to be aware of:
Primary language spoken by the family:
Primary language spoken by the child:
If the child is non-verbal, please describe how they communicate with you:
Please list any cultural or religious considerations or requests to be aware of:
Primary Concerns
What are your primary concerns?
Communication
Sibling Aggression
Sensory Seeking
Social Skills
Following Directions
Fine Motor Skills
Self-Care
Balance/Mobility
Handwriting
Behavior
Community Independence
Feeding
Non-Verbal
General Aggression
Toileting
Behaviors
Please check any of the following behaviors that apply to your child:
Cries Often
Frequent temper tantrums
Anxious
Trouble following directions
Trouble with change in routine
Clumsy
Weak muscles
Picky eater
Mouths objects
Dislikes hair brushing
Dislikes tooth brushing
Avoids touch from others
Dislikes playground equipment
Seems to be "on the go"
Rocks self
Sensitivity to light
Sensitivity to sound
Poor attention span
Educational Information
Are there any traumatic events that have taken place during school/educational programs that we should be aware of? If so, please explain what happened:
School/Educational Program currently attending:
Present grade level:
Does your child receive any of the following?
Special Education
Behavior Intervention
Other
Services received in school:
Occupational Therapy
Speech Therapy
Physical Therapy
Other
Does your child have a 504 or IEP?
Please Select
IEP
504
N/A
Does your child's teacher have any concerns with your child's development in the following areas?
Motor Skills
Social Abilities
Self-Help skills
Learning Abilities
Previous Services
Has your child previously received any of the following services?
ABA
Occupational Therapy
Speech Therapy
Mental Health Counseling
Physical Therapy
Other
Additional Services Information
Please provide any additional information regarding the type of services received, (including but not limited to session days, times, and a general overview of what a typical session looked like):
Therapy Goals
Please provide a brief description of what you are hoping to achieve through services with Learning Solutions:
Helpful Information
What are your child's strengths?
Please list any extracurricular activities your child enjoys engaging in:
Does your child demonstrate difficulty with separating from caregivers?
Does your child handle transition from activities well? What helps them?
Please list your child's preferred activities and/or typical routines:
Please list your child's fears and dislikes:
In your opinion, what would be helpful for your child to more easily establish trust and engage with a person/therapist?
Do you have adequate people to depend on and help you with your child when you need respite?
Please list things your child would find motivating in therapy (i.e. Stickers, treats, certain cartoon characters, etc.)
Current Skills
Select the level of performance your child can complete (Always, Sometimes, Rarely, Never)
Can independently dress self:
Always
Sometimes
Rarely
Never
Needs occasional assistance to dress:
Always
Sometimes
Rarely
Never
Parent dresses child on daily basis:
Always
Sometimes
Rarely
Never
Can zip and button clothing:
Always
Sometimes
Rarely
Never
Is starting to push arms through sleeves, legs through pants:
Always
Sometimes
Rarely
Never
Feeding Skills
Uses spoons/forks at every meal:
Always
Sometimes
Rarely
Never
Uses utensils
Always
Sometimes
Rarely
Never
Willing to sit at a table/highchair for all meals:
Always
Sometimes
Rarely
Never
Occasionally or needs reminders to use utensils:
Always
Sometimes
Rarely
Never
Eats an adequate amount of food for his/her age:
Always
Sometimes
Rarely
Never
Motor Skills
Appear clumsy/uncoordinated
Always
Sometimes
Rarely
Never
Fatigues easily and poor endurance:
Always
Sometimes
Rarely
Never
Has difficulties learning new motor skills:
Always
Sometimes
Rarely
Never
Social Interaction
Plays with age-appropriate toys:
Always
Sometimes
Rarely
Never
Has difficulties with transactions to new activities/environment:
Always
Sometimes
Rarely
Never
Has poor frustration tolerance:
Always
Sometimes
Rarely
Never
Has difficulties calming and coping with anger:
Always
Sometimes
Rarely
Never
Responds when his/her name is called:
Always
Sometimes
Rarely
Never
Has difficulties with change in routine
Always
Sometimes
Rarely
Never
Has poor safety awareness in the community
Always
Sometimes
Rarely
Never
Parental concerns about child's ability to play with other children?
Always
Sometimes
Rarely
Never
Sensory Processing
Washing/Cutting Hair:
Always
Sometimes
Rarely
Never
Brushing teeth/oral care:
Always
Sometimes
Rarely
Never
Clothing textures/fabrics:
Always
Sometimes
Rarely
Never
Avoids messy play/getting dirty
Always
Sometimes
Rarely
Never
Cutting fingernails:
Always
Sometimes
Rarely
Never
Loud and Unexpected Noises:
Always
Sometimes
Rarely
Never
Avoids swings/climbing/movement
Always
Sometimes
Rarely
Never
Do any of the following statements describe your child?
Difficulties calming down:
Always
Sometimes
Rarely
Never
Engages in risky play activities:
Always
Sometimes
Rarely
Never
Craves movement:
Always
Sometimes
Rarely
Never
Difficulties focusing attention:
Always
Sometimes
Rarely
Never
Prefers rough play:
Always
Sometimes
Rarely
Never
Constantly "on the go":
Always
Sometimes
Rarely
Never
Speech/Language Skills
Describe your speech/language/feeding concerns (if any)
How is your child currently communicating with you?
How much of your child's speech do you understand?
more than 75%
50%
less than 25%
Please check all that apply to your child:
Answers yes/no questions
Answers wh questions
Identifies basic body parts
Follows directions
Difficult to understand
Difficulty reading
Difficulty with memory
Messy eater
Choking/gagging/coughing during eating or drinking
Session Scheduling
Check all that apply:
Session Scheduling Availability:
8:00am-10:00am
9:00am-11:00am
10:00am-12:00pm
11:00am-1:00pm
1:00pm-3:00pm
2:00pm-4:00pm
3:00pm-5:00pm
4:00pm-6:00pm
Birth History
Child was born:
Full Term
Premature
If premature, how many weeks?
Delivery:
Vaginal
With Forceps
C-Section
Were there any complications?
Was your child placed in the Newborn Intensive Care Unit? If so, for how long?
Please describe any other medical problems or complications at birth:
Medical History
Child's Primary Care Physician:
Has your child had any surgeries? If yes, please describe:
Has your child been hospitalized? If yes, please describe:
Has your child had a previous psychological evaluation? If yes, please describe:
Is your child on any medications? If yes, please describe:
Does your child use any special equipment? If yes, please describe:
Any feeding problem or nutritional concerns? If yes, please describe:
Has your child had frequent ear infections?
Please check all that apply to your child:
Trach
Hearing Aids
C-Line
Hearing difficulty
G-Tube
Allergies
Wears glasses
Latex sensitivity
Vision problems
Seizures
As the client or as the client's legal guardian, I certify that the information expressed in this document is accurate to the best of my knowledge. I also declare my intent to pursue services with Learning Solutions LLC as directed by the referring physician. If I plan to pay for services through an insurance company, I understand that treatment and service hours will depend on approval and authorization. If I plan to pay for services through private funds, I understand that treatment and service hours will depend on approval from whatever source promises funds.
*
Submit
Submit
Should be Empty: