Client History Information Form

Nombre de niño/a

NombreApellido

Género de niño

Apodo preferido

Cumpleaños de niño

Nombre de padre/madre

Primer NombreApellido

Nombre de padre/madre

Primer NombreApellido

Correo Electrónico 1

ejemplo@ejemplo.com

Correo Electrónico 2

ejemplo@ejemplo.com

Número de teléfono

Area CodePhone Number

Número de teléfono

Area CodePhone Number

Dirección 1

Street Address

Dirección

CiudadEstado

código postal

Dirección 2

Dirección

CiudadEstado

Codigo Postal

Compañía de Seguros

Número de Seguros (niño)

Compañía de Seguros secondario

Número de Seguros secondario

Información del contacto de su Asistente Social

Médico de atención primaria

Idioma primaria

Idiomas Adicionales Hablados en Casa:

Origen Étnico (opcional)

Autism Diagnosis

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?

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:

Were there any difficulties with your pregnancy or birth?

(e.g., premature, gestational diabetes, etc.)

Please list any medications your child is currently taking:

Rows	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.)

Please select all current concerns you have regarding your child.

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:

Inappropriate behavior concerns

Please describe these behavior concerns:

Sensory Issues

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.

Please list all supplements your child takes:

Is sleep a primary concern at this time? If so, how?

Please select all concerns you have regarding your child's sleep:

Have you tried any form of sleep intervention? Select all that apply.

What were the results of the intervention?

Is toileting a primary concern at this time?

Does your child remain dry during the night?

Is your child trip trained for urine?

If so, please describe their current schedule:

Is your child trip-trained for bowel movements?

If so, please describe their current schedule:

Does your child recognize being wet?

Does your child dislike being wet?

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?

Are you maintaining this routine, or have you discontinued it?

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:

If you checked any of the above boxes, please list that person's relationship to your child:

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)

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.

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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:

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.

Rows	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.

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Client History Information Form

Child Information

Información Familiar

Medical History

Medications

Current Concerns

Sleep Concerns

Toileting Issues

Family Goals

Developmental History

School History