nb New Client Intake Form

New Client Intake Form
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Clinician*
Parent 1 or Legal Guardian’s Name*

First NameLast Name
Parent 1 or Legal Guardian's Email Address*
example@example.com
Parent 1 or Legal Guardian’s Mobile Phone*

Area CodePhone Number
Parent 2 Name

First NameLast Name
Parent 2 Email Address
example@example.com
Parent 2 Mobile Phone

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Lives with*
Please list all household members.
Age of Siblings*
Please list ages of all siblings.
Additional Caregivers

NannyGrandparentSitterOther
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?

MondayTuesdayWednesdayThursdayFriday
Drop Off Time

:HourMinutesAM/PM Option
Pick Up Time

:HourMinutesAM/PM Option
What grade/teacher’s name?*
Hand preference?*

RightLeftNot established
Does your child receive any educational support?

MathReadingOther
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.

HappyEnergeticAffectionateFriendlyWithdrawnStubbornSensitiveApatheticOther
What behavioral characteristics does your child display? Select all that apply.

CooperativeWilling to Try New ActivitiesSeperation DifficultiesStubbornEasily frustratedImpulsiveEasily DistractedFidgetyDifficulty Transitioning Between ActivitiesAnxiousRigid
Your child is sensitive to:

LightSoundSmellsCertain Clothing TexturesFood TexturesOther
Additional information you would like to share?*
Has your child ever had any previous evaluations and/or therapy services?*

YesNo
Please check the evaluation and/or therapy services that apply.*

Occupational TherapySpeech TherapyPhysical TherapyApplied Behavioral AnalysisAcademic TestingOther
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 ComplicationsPrematureDelivery ComplicationsOxygen Given at BirthNICU 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 FedBottle 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.

ADHDAutismSpeech ErrorsLanguage DelaysHearing ImpairmentReading/Learning Delay
Child’s Health
Has your child had any of the following? Select all that apply.

Frequent Ear InfectionsGastrointestinal (GI) DifficultiesFeeding TubeFrequent Stomach AchesIrregular Bowel MovementsPE TubesBroken BonesHead InjuriesVision ProblemsWears GlassesHearing ProblemsWears Hearing AidsDiet RestrictionsAllergiesMedications(s)TonsillectomyAdenoidectomySurgery
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 easilySleeps in own bedTakes melatoninWakes up frequently throughout the nightSleeps 10 or more hours per nightOther
Which of the following dietary behaviors apply to your child? Select all that apply.

Picky eaterEats a variety of foodsStrong food preferencesOther
Which of the following screen (tablet/TV) time behaviors apply to your child? Select all that apply.

Has screen time before schoolHas screen time after schoolHas screen time in the carHas difficulty transitioning away from screensOther
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?*

YesNo
Does your child have difficulty having a bowel movement and/or frequent accidents?*

YesNo
Does your child complain of frequent stomach aches?*

YesNo
Developmental Milestones
How did your child crawl?

Traditional (on all fours)Army CrawlBottom ScootOther
Child spoke first word(s) between

9-12 Months12-18 Months18-24 MonthsOther
Child spoke first sentences between

2 - 2.5 Years2.5 - 3 Years3 - 3.5 YearsOther

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 DressingPutting on socksUsing buttonsUsing zippersTying shoesUsing utensilsWashing handsDrinking from an open cupDrinking from a straw
Does your child put on underwear, shirts, and pants without help?*

YesNo
Does child tie shoes without help?*

YesNo
Does child zip without help?*

YesNo
Button without help?*

YesNo
Does your child use utensils without help?*

YesNo
Given supervision, does child bathe/shower without help?*

YesNo
Does your child put on socks without help?*

YesNo
Communication Skills
Does your child do the following? Select all that apply.

StutterRepeat sounds, words, and/or phrases repetitivelyFrequently 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 questionsRespond correctly to who/what/where/when/why questionsMakes wants and needs knownBecomes frustrated when attempting to communicateParticipates in simple conversation
Your child currently communicates using? Select all that apply.

Body LanguageSounds (vowels, grunting)Words2- to 4-word sentencesUses sentences longer than 4 wordsUses 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?*

YesNo
List languages spoken in your home
Does your child speak the language?

YesNo
Does your child understand the language?

YesNo
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?*

YesNo
Does your child have speech sound errors?*

YesNo
Does your child ask for help?*

YesNo
Using words or gestures?*
Is your child ever frustrated when trying to communicate?*

YesNo
Does your child follow directions at home?*

YesNo
Does your child stutter when trying to communicate?*

YesNo
Social Communication/Emotional Regulation
Check all that apply to your child's play/peer interaction?

Prefers to watch others playMakes friends easilyTakes turnsPlays separatelyCopies othersPrefers cause/effect toysPrefers building toysEngages in pretend playPlays cooperatively with othersExpresses/understands feelings of selfUnderstands how others are feeling
Does your child have a variety of interest/toys?

YesNo
Additional information you would like to share?
Does your child demonstrate age appropriate skills for making friends?*

YesNo
Does your child demonstrate age appropriate skills for entering a play circle?*

YesNo
Does your child demonstrate age appropriate skills for expressing/understanding feelings?*

YesNo
Does your child have a variety of interests and maintain topic of conversation for a variety of subjects?*

YesNo
Does your child usually react appropriately to: problems and/or changes in routine?*

YesNo
Describe your child as an infant
Cried a lot/fussy?*

YesNoSometimes
Demanding?*

YesNoSometimes
Quiet?*

YesNoSometimes
Liked being held?*

YesNoSometimes
Active?*

YesNoSometimes
Good sleep patterns?*

YesNoSometimes
Printed Name
E-mail*
Please enter your email to receive a record of this form.
Should be Empty:

New Client Intake Form

Education/Social History

Prenatal/Birth History

Family History

Child’s Health

Sleep/GI

Developmental Milestones

Self Help Skills

Communication Skills

Social Communication/Emotional Regulation

Describe your child as an infant