Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

Multiple Births *

Yes

No

Complications (please check all that may apply) *

Rapid

Prolonged

Breech

Caesarean

Other (describe below)

No Complications

Baby's Health *

Jaundice

Breathing Problems

Incubator

Abnormalities

Medical Conditions

Other (describe below)

No Health Abnormalities or Concerns

Feeding Problems as an Infant? *

Yes

No

Does your child have any speech problems or delays? *

Yes

No

Do you understand your child's speech? *

Yes

No

Do strangers understand your child's speech? *

Yes

No

Does your child understand and/or speak another language besides English? *

Yes

No

Do you think your child has a hearing problem? *

Yes

No

Has your child's hearing been tested? *

Yes

No

Has your child had any of the following medical conditions? *

RSV

Measles

Rubella

Chicken Pox

Mumps

Lyme's

GERD

Asthma

Torticollis

High Fever (specify what age)

Ear Infections (specify amount and at what age)

Hypotonia

Sprains/Fractures (specify where)

Other

Has your child been diagnosed with any of the following neurological conditions? *

Autism Spectrum

ADHD

Seizures

Head Injury

Other

No diagnosed neurological conditions

Does your child have any allergies? *

Yes

No

Have your child's eyes been examined? *

Yes

No

Does your child sleep through the night? *

Yes

No

Does your child have difficulty in any of the following ares? *

Learning Problems

Handwriting

Reading

Riding a Bike

Gym/Sports

None of the Above

Are you currently receiving services elsewhere (Behavioral Support, Speech, Occupational Therapy, Physical Therapy)? *

Yes

No

Have you received any of the above services in the past? *

Yes

No