New Client Intake Form
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Clinician
*
Margaret
Sarah
Brooke
Lanie
Karen
Andrea
Julie
Lizzie
Rachel
Lauren
Kim
Anna
Abbey
Nicole
Tamyra
Parent 1 or Legal Guardian’s Name
*
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
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Lives with
*
Please list all household members.
Age of Siblings
*
Please list ages of all siblings.
Additional Caregivers
Nanny
Grandparent
Sitter
Other
Primary Physician
*
Medical Diagnosis
Emergency Contact Name/Relationship/Cell Phone
*
Who may we thank for referring your child to n euroBridge?
Education/Social History
Where does your child go to school?
*
Which days?
Monday
Tuesday
Wednesday
Thursday
Friday
Drop Off Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
AM/PM Option
Pick Up Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What grade/teacher’s name?
*
Hand preference?
*
Right
Left
Not established
Does your child receive any educational support?
Math
Reading
Other
Does your child receive any special support (therapy, counseling) during his/her day? Have they in the past?
Has your child ever repeated a grade? If yes, What grade?
*
Has your child received any formal education testing? If so, what and when?
*
In what extracurricular activities does your child participate?
*
List your child’s strengths:
*
List any concerns you have about your child:
*
What would you like to see your child doing in the next 6 months?
*
Are there any stressful events occurring in your family that might be affecting the child?
*
What are your child's favorite activities, hobbies, shows/movies, books, toys, etc.?
*
What motivates your child?
*
What is the general disposition of your child? Select all that apply.
Happy
Energetic
Affectionate
Friendly
Withdrawn
Stubborn
Sensitive
Apathetic
Other
What behavioral characteristics does your child display? Select all that apply.
Cooperative
Willing to Try New Activities
Seperation Difficulties
Stubborn
Easily frustrated
Impulsive
Easily Distracted
Fidgety
Difficulty Transitioning Between Activities
Anxious
Rigid
Your child is sensitive to:
Light
Sound
Smells
Certain Clothing Textures
Food Textures
Other
Additional information you would like to share?
*
Has your child ever had any previous evaluations and/or therapy services?
*
Yes
No
Please check the evaluation and/or therapy services that apply.
*
Occupational Therapy
Speech Therapy
Physical Therapy
Applied Behavioral Analysis
Academic Testing
Other
Please briefly describe the details of the evaluation and/or therapy services. When was it? Where was it? What were you told?
*
Prenatal/Birth History
Check all that apply:
Pregnancy Complications
Premature
Delivery Complications
Oxygen Given at Birth
NICU Stay
Provide further information for any boxes checked above.
My child was born at how many weeks?
Weeks
What was the child’s weight?
*
How was your child fed?
Breast Fed
Bottle Fed
Were there any issues with feeding? If so, please describe.
Was child full term? Please list at how many weeks the child was born
*
Were there any pregnancy complications?
*
Were there any complications during delivery?
*
Was the child required to stay in the Neonatal Intensive Care Unit?
*
Family History
Does your family have a history of the following: Select all that apply.
ADHD
Autism
Speech Errors
Language Delays
Hearing Impairment
Reading/Learning Delay
Child’s Health
Has your child had any of the following? Select all that apply.
Frequent Ear Infections
Gastrointestinal (GI) Difficulties
Feeding Tube
Frequent Stomach Aches
Irregular Bowel Movements
PE Tubes
Broken Bones
Head Injuries
Vision Problems
Wears Glasses
Hearing Problems
Wears Hearing Aids
Diet Restrictions
Allergies
Medications(s)
Tonsillectomy
Adenoidectomy
Surgery
Please provide additional details for areas selected above.
Any known allergies?
*
Which of the following sleep behaviors apply to your child? Select all that apply.
Falls asleep easily
Sleeps in own bed
Takes melatonin
Wakes up frequently throughout the night
Sleeps 10 or more hours per night
Other
Which of the following dietary behaviors apply to your child? Select all that apply.
Picky eater
Eats a variety of foods
Strong food preferences
Other
Which of the following screen (tablet/TV) time behaviors apply to your child? Select all that apply.
Has screen time before school
Has screen time after school
Has screen time in the car
Has difficulty transitioning away from screens
Other
Has the child had an eye exam by a doctor in the last year?
*
Does child wear glasses?
*
Any diet restrictions? If yes, please explain:
*
Date and results of child’s last hearing screening?
*
Is there a history of chronic ear infections?
*
Did child require PE (ear) tubes?
*
Has child had any broken bones? If yes, please explain:
*
Please list any medical or surgical procedures to date:
*
Has child ever sustained a serious fall or lost consciousness? If yes, please explain
*
Please list any current medications:
*
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?
*
Yes
No
Does your child complain of frequent stomach aches?
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Yes
No
Developmental Milestones
How did your child crawl?
Traditional (on all fours)
Army Crawl
Bottom Scoot
Other
Child spoke first word(s) between
9-12 Months
12-18 Months
18-24 Months
Other
Child spoke first sentences between
2 - 2.5 Years
2.5 - 3 Years
3 - 3.5 Years
Other
Type a question
*
Rows
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
Your child is independent with the following: Select all that apply.
Simple Dressing
Putting on socks
Using buttons
Using zippers
Tying shoes
Using utensils
Washing hands
Drinking from an open cup
Drinking from a straw
Does your child put on underwear, shirts, and pants without help?
*
Yes
No
Does child tie shoes without help?
*
Yes
No
Does child zip without help?
*
Yes
No
Button without help?
*
Yes
No
Does your child use utensils without help?
*
Yes
No
Given supervision, does child bathe/shower without help?
*
Yes
No
Does your child put on socks without help?
*
Yes
No
Communication Skills
Does your child do the following? Select all that apply.
Stutter
Repeat sounds, words, and/or phrases repetitively
Frequently repeats words/phrases previously heard (in movies/shows, etc.)
Can retrieve/point to common objects upon request (e.g.: ball, cup, shoe)
Follow simple directions (e.g.: shut the door, get your shoes)
Follow multi-step directions (e.g.: before you get your shoes, brush your teeth)
Respond correctly to yes/no questions
Respond correctly to who/what/where/when/why questions
Makes wants and needs known
Becomes frustrated when attempting to communicate
Participates in simple conversation
Your child currently communicates using? Select all that apply.
Body Language
Sounds (vowels, grunting)
Words
2- to 4-word sentences
Uses sentences longer than 4 words
Uses an iPad/communication device
Please provide any additional information you feel we need to know related to your child's speech and language:
Are languages (other than English) spoken in your home?
*
Yes
No
List languages spoken in your home
Does your child speak the language?
Yes
No
Does your child understand the language?
Yes
No
What was your child's first language?
At what age was your child exposed to English?
Years
What is the primary language spoken by adults in your home?
Does your child communicate in sentences?
*
Yes
No
Does your child have speech sound errors?
*
Yes
No
Does your child ask for help?
*
Yes
No
Using words or gestures?
*
Is your child ever frustrated when trying to communicate?
*
Yes
No
Does your child follow directions at home?
*
Yes
No
Does your child stutter when trying to communicate?
*
Yes
No
Social Communication/Emotional Regulation
Check all that apply to your child's play/peer interaction?
Prefers to watch others play
Makes friends easily
Takes turns
Plays separately
Copies others
Prefers cause/effect toys
Prefers building toys
Engages in pretend play
Plays cooperatively with others
Expresses/understands feelings of self
Understands how others are feeling
Does your child have a variety of interest/toys?
Yes
No
Additional information you would like to share?
Does your child demonstrate age appropriate skills for making friends?
*
Yes
No
Does your child demonstrate age appropriate skills for entering a play circle?
*
Yes
No
Does your child demonstrate age appropriate skills for expressing/understanding feelings?
*
Yes
No
Does your child have a variety of interests and maintain topic of conversation for a variety of subjects?
*
Yes
No
Does your child usually react appropriately to: problems and/or changes in routine?
*
Yes
No
Describe your child as an infant
Cried a lot/fussy?
*
Yes
No
Sometimes
Demanding?
*
Yes
No
Sometimes
Quiet?
*
Yes
No
Sometimes
Liked being held?
*
Yes
No
Sometimes
Active?
*
Yes
No
Sometimes
Good sleep patterns?
*
Yes
No
Sometimes
Printed Name
E-mail
*
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