New Client Questionnaire

New Client Questionnaire fionazecca.com
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent name
Address
Phone #
Format: (000) 000-0000.
Email
example@example.com
Occupation
Child's name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Who referred you?
Does your child have any siblings? Who lives with your child? If shared custody, what is the schedule?
What language(s) does your child speak? What language is predominately spoken at home?
What school does your child go to?
In a few words please describe your child
What are your concerns, why are you seeking assistance?
Has your child ever been given a diagnosis? If so, what was it and by whom?
Is your child currently receiving any therapy (i.e.: speech, OT, PT, counseling)? How often and who is the provider (facility and specialist/therapist name)?
Is your child in any programs besides school with other children his/her age? Please list/explain
Does your child have favorite games, songs, and/or toys he/she likes to play with?
How do you comfort your child?
How do you handle challenging or difficult behaviors?
What is your screen time policy? How often is your child allowed to be on screens?
What sensory inputs seem most uncomfortable for your child (touch, smells, sounds, body positions/actions, etc.) what does he/she AVOID?
What sensory inputs seem most organizing or soothing to your child - what does he/she CRAVE or seek out?
Please list 3 SPECIFIC things you would like to be different in your family life (these will be the goals of our sessions):
1)
2)
3)
Other comments?
Please email all current/relevant assessment or progress reports from any specialists
Should be Empty: