New Client Intake Form
Child's Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Date Picker Icon
Age
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Clinician
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Margaret
Sarah
Brooke
Anna
Lanie
Karen
Kim
Parent 1 or Legal Guardian’s Name
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First Name
Last Name
Parent 1 or Legal Guardian”s Email Address
*
example@example.com
Parent 1 or Legal Guardian’s Mobile Phone
*
-
Area Code
Phone Number
Parent 2 Name
First Name
Last Name
Parent 2 Email Address
example@example.com
Parent 2 Mobile Phone
-
Area Code
Phone Number
Child lives with
please list all household members
Primary Physician
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Diagnosis
Emergency Contact Name/Relationship/Cell Phone
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Who may we thank for referring your child to n euroBridge?
Has your child ever had any previous evaluations and/or therapy services? If so,where?
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Prenatal/Birth History
Was child full term? Please list at how many weeks the child was born
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What was the child’s weight?
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Were there any pregnancy complications?
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Were there any complications during delivery?
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Was the child required to stay in the Neonatal Intensive Care Unit?
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Child’s Health
Any known allergies?
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Has the child had an eye exam by a doctor in the last year?
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Does child wear glasses?
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Any diet restrictions? If yes, please explain:
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Date and results of child’s last hearing screening?
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Is there a history of chronic ear infections?
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Did child require PE (ear) tubes?
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Has child had any broken bones? If yes, please explain:
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Please list any medical or surgical procedures to date:
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Has child ever sustained a serious fall or lost consciousness? If yes, please explain
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Please list any current medications:
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Sleep/GI
Does your child have difficulty falling asleep and/or staying asleep?
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Yes
No
Does your child have difficulty having a bowel movement and/or frequent accidents?
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Yes
No
Does your child complain of frequent stomach aches?
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Yes
No
Developmental Milestones
Please list the age your child was able to perform each without help
Type a question
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Age
Comments
Babbling
First word spoken
Spoke in sentences
Eating finger foods
Fed self with spoon
Drank from a sippy cup
Rolled over
Sat without help
Crawled / What type of crawling?
Walked
Potty Trained
Slept through the night independently
Self Help Skills
Does your child put on underwear, shirts, and pants without help?
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Yes
No
Does child tie shoes without help?
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Yes
No
Does child zip without help?
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Yes
No
Button without help?
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Yes
No
Does your child use utensils without help?
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Yes
No
Given supervision, does child bathe/shower without help?
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Yes
No
Does your child put on socks without help?
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Yes
No
Communication Skills
Does your child communicate in sentences?
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Yes
No
Does your child have speech sound errors?
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Yes
No
Does your child ask for help?
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Yes
No
Using words or gestures?
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Is your child ever frustrated when trying to communicate?
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Yes
No
Does your child follow directions at home?
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Yes
No
Does your child stutter when trying to communicate?
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Yes
No
Social Communication/Emotional Regulation
Does your child demonstrate age appropriate skills for making friends?
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Yes
No
Does your child demonstrate age appropriate skills for entering a play circle?
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Yes
No
Does your child demonstrate age appropriate skills for expressing/understanding feelings?
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Yes
No
Does your child have a variety of interests and maintain topic of conversation for a variety of subjects?
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Yes
No
Does your child usually react appropriately to: problems and/or changes in routine?
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Yes
No
Describe your child as an infant
Cried a lot/fussy?
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Yes
No
Sometimes
Demanding?
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Yes
No
Sometimes
Quiet?
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Yes
No
Sometimes
Liked being held?
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Yes
No
Sometimes
Active?
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Yes
No
Sometimes
Good sleep patterns?
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Yes
No
Sometimes
Education/Social History
Where does your child go to school?
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What grade/teacher’s name?
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Hand preference?
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Right
Left
Not established
Does your child receive any special support (therapy, counseling) during his/her day? Have they in the past?
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Has your child ever repeated a grade? If yes, What grade?
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Has your child received any formal education testing? If so, what and when?
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In what extracurricular activities does your child participate?
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List your child’s strengths:
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List any concerns you have about your child:
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What do you hope your child will achieve by receiving services at neuroBridge?
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Are there any stressful events occurring in your family that might be affecting the child?
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Additional information you would like to share?
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Printed Name
E-mail
Please enter your email to receive a record of this form.
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