Client History Information Form
Please fill out the form to the best of your ability. Take note, this form is long, and may take a while to complete.
Child Information
Child's Name
*
First Name
Last Name
Child's Gender
*
Male
Female
Non-binary
Prefer not to answer
Preferred Nickname
Child's Birthday
*
Family Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Phone Number
-
Area Code
Phone Number
Client Address 1
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Address 2 (Optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Insurance Provider
*
Child's Member Number
*
Secondary Insurance Provider
Secondary Insurance Member Number
Tertiary Insurance Provider
Tertiary Insurance Member Number
Care Coordinator/Caseworker Contact Information
Client's Primary Care Physician
*
Primary Language:
*
Additional Languages Spoken in the Home:
Ethnic Background (Optional)
¿Cuál es su idioma principal/preferido para la comunicación oral?¿Cuál es su idioma principal/preferido para la comunicación escrita?
您口头交流的主要/首选语言是什么？您书面交流的主要/首选语言是什么？
Ngôn ngữ chính/ưu tiên của bạn để giao tiếp bằng lời nói là gì?Ngôn ngữ chính/ưu tiên của bạn để giao tiếp bằng văn bản là gì?
Какой язык является вашим основным/предпочтительным для устного общения?Какой язык является вашим основным/предпочтительным для письменного общения?
Ano ang inyong pangunahing/nais na wika para sa oral na komunikasyon?Ano ang inyong pangunahing/nais na wika para sa pagsusulat na komunikasyon?
구두 의사 소통에 사용하는 기본/선호 언어는 무엇인가요?서면 의사 소통에 사용하는 기본/선호 언어는 무엇인가요?
Medical History
Autism Diagnosis
-
Month
-
Day
Year
Date
Diagnosing Physician
Other medical diagnoses (please include dates):
Most recent hearing screen (please include date and results):
Most recent vision screen (please include date and results):
Does your child have allergies, if yes, to what?
Is your child up to date on vaccines/immunizations?
Yes
No
Has your child ever had surgery?
If yes, please list procedures, hospital used, and dates:
Has your child ever been hospitalized overnight?
If yes, please list date, hospital, and reason.
Has your child ever had any major injuries?
If yes, please describe.
Has your child ever had problems with:
Seizures
Asthma
Diabetes
Fatigue
Constipation (frequent)
Hearing or ear problems
Eye or vision problems
Sleep problems
Traveling in the car
Behavior in community settings
Stranger Danger
Were there any difficulties with your pregnancy or birth?
(e.g., premature, gestational diabetes, etc.)
Medications
Please list any medications your child is currently taking:
Medication
Purpose
Who Prescribes?
How often?
Dosage
Are there any other medications or supplements your child has taken in the past?
Has your child ever seen a psychologist, psychiatrist, or counselor?
If yes, when? How long? For what reason? Was it helpful?
Please describe any other medical evaluations your child has had:
(e.g. neurology, MRI, EEG, genetics, gastroenterology, etc.)
Current Concerns
Please select all current concerns you have regarding your child.
Communication Skills
Behavior Problems
Sensory Differences
Academic Problems
Social Skills
Motor Skills
Medical Problems
Other
Of these, what is your #1 concern?
Please describe your main concern for your child:
When did you first have these concerns?
What has been tried to address these concerns? What was the outcome?
(i.e., prior services including dates, frequency and type of service)
What are your child's strengths?
Please list any major stressors or events that your child has experienced, along with the dates.
Please list all current diagnoses, with dates for each diagnosis:
Areas of concern:
Attending/Level of distractibility
Motor Imitation
Verbal Imitation
Receptive Language
Expressive Language (nonberbal)
Communication/Mands
Play
Socialization with adults
Socialization with peers and siblings
Overall independence (bathing, dressing, grooming)
Inappropriate behavior concerns
Verbal Sterotypy
Physical Sterotypy
Aggression toward adults
Aggression toward animals
Aggression toward peers/siblings
Tantrums
Destructive behaviors (breaking, ripping, throwing, swiping)
Please describe these behavior concerns:
Sensory Issues
Fine motor difficulties
Gross motor difficulties
Low sensory threshold
High sensory threshold
Sensitivity to sound
Sensitivity to light
Sensitivity to touch
Sensitivity to texture
Other
Please describe your child's sensory issues:
Is eating a primary concern at this time?
If so, please describe how.
Does your child have any dietary restrictions? Select all that apply.
GFCF Diet
Soy restricted/free
Refined sugar restricted/free
Artificial dyes restricted/free
Supplements
Other
Please list all supplements your child takes:
Sleep Concerns
Is sleep a primary concern at this time? If so, how?
Please select all concerns you have regarding your child's sleep:
Easy to put to bed
Sleeps through the night
Remains in bed
Cyclical sleep patterns
Erratic sleep patterns
Have you tried any form of sleep intervention? Select all that apply.
Medication
Homeopathic
Behavioral
What were the results of the intervention?
Toileting Issues
Is toileting a primary concern at this time?
Does your child remain dry during the night?
Yes
No
Is your child trip trained for urine?
Yes
No
If so, please describe their current schedule:
Is your child trip-trained for bowel movements?
Yes
No
If so, please describe their current schedule:
Does your child recognize being wet?
Yes
No
Does your child dislike being wet?
Yes
No
Does your child experience urine-related irregularities? If so, please describe.
Does your child experience bowel movement-related irregularities? If so, please describe.
Have you initiated a toilet-training routine with your child?
Yes
No
Are you maintaining this routine, or have you discontinued it?
Maintaining
Discontinued
Family Goals
What are your short-term goals for your child and family?
What are your long-term goals for your child and family?
Does anyone in the child's family have a history of the following:
Speech or language problems
Reading problems/Dyslexia
Learning disabilities
ADHD
Schizophrenia
Depression
Anxiety
Bipolar disorder/manic depression
Intellectual Disability
Alcoholism/Substance Abuse
Autism/Asperger's Disorder/PDD
Seizures/Epilepsy
Genetic Disorder
Psychiatric hospitalization
Other significant problems
Other
If you checked any of the above boxes, please list that person's relationship to your child:
Developmental History
At what age did your child first roll over?
At what age did your child first sit independently?
At what age did your child first crawl?
At what age did your child take their first steps?
At what age did your child first smile?
At what age did your child first play games, like peek-a-boo?
At what age did your child first babble?
At what age did your child first use single words?
At what age did your child first use short phrases?
At what age did your child first use sentences?
At what age did your child first toilet train during the day?
At what age did your child first toilet train during the night?
As an infant and toddler, (ages birth-3), was your child (mark all that apply)
Interested in people
Interested in toys
Overly active
Underactive
Easy to please
Able to be flexible (Easy going)
Irritable/cranky
Difficult to soothe
Difficult to nurse or feed
Difficult to get to sleep
School History
Does your child attend preschool or daycare? If so, please list the name of your child's current school:
Does your child receive Early Intervention or Early Childhood Special Education?
If you answered yes to the previous question, please provide a copy of the most recent IEP or IFSP.
Browse Files
Cancel
of
If your child does not attend school/daycare, please describe any opportunities your child has to play with other children their age (activities, church groups, playdates, etc.).
Do you have any concerns about your child's pre-academic skills (letters, numbers, shapes, colors, drawing/writing, etc.)? If so, please describe:
Do you have any concerns about your child's play skills (curiosity about the environment, pretend play, playing with other children, unusual behaviors in play)? If so, please describe:
What grade is your child in?
Name of current school:
Teacher's name (please list all):
Number of children in classroom:
Number of teachers in classroom:
Does your child have one-on-one classroom support?
Please list all other schools your child has attended, along with the number of years and grades:
Does your child receive special education services? If so, what is the special education eligibility category?
School-based related service providers:
SLP
OT
PT
Other
Does your child receive other extra help in school not covered by an IEP? (i.e. modification, tutoring, etc.) If so, please list:
Has your child ever repeated a grade?
Has your child ever skipped a grade?
Has your child ever been suspended?
Has your child ever been expelled?
Does your child often get in trouble at school? If so, please describe:
Does your child participate in any extracurricular activities (e.g. sports, clubs, religion-affiliated groups, Boy/Girl Scouts, camps, etc.)? If so, please describe:
Does your child see any private related service providers? If so, please list the number of hours per week or month, where your child receives these services. Examples: OT, SLP, PT, etc.
Please fill out this form in as much as detail as possible, including providing specifics (e.g. brand, type, etc.). This information will be very helpful in establishing/maintaining motivation as we begin your child's personalized program.
Highly Preferred
Moderately Preferred
Dislikes
Additional Notes
Edibles (snacks, food)
Tangibles (toys, games)
Activities (games, hobbies, interests, music, sounds)
People (family members, friends, acquaintences)
Places (regularly visited or availble)
Sensory (Auditory, visual, tactile, movement, smell, tasete)
Please attach all relevant materials to your child's diagnosis and previous treatment. This includes items such as a diagnosis letter, any IEPs, hearing screenings, etc.
Browse Files
Cancel
of
Save
Submit
Should be Empty: