All information contained in this form is confidential and will not be shared without written consent by the client.
Child's Name (First Last) *
Address *
Home Phone *
Current Age *
Height *
Current Weight *
Diagnosis if Any *
Age at Diagnosis
Mother's Name (First Last) *
Mother's Cell Phone
Mother's Email Address
Father's Name (First Last) *
Father's Cell Phone
Father's Email Address
Siblings (names and ages) *
How Many and Type?
Has The Child Ever Had ABA Therapy? Yes No *
How Long Was ABA Therapy Used?
Frequency of ABA?
Was This a Home Program? Yes No
Has The Child Ever Had Speech Therapy? Yes No *
Please List Any Other Therapies
Please describe any skills or issues the child has in the following areas.
Sleep *
Feeding
Toileting *
Self Care *
Dressing *
Self Stimulating Behavior (Stims) *
Sensory Problems *
Emotional Problems *
Expressive Language *
Receptive Language *
What Kinds Of Foods Does Your Child Mostly Eat? *
Vitamins/Supplements/Medications? Describe. *
Any Elimination Diets Attempted? Describe. *
Food Cravings? Describe. *
Pediatrician *
Medical Tests? Describe. *
Illnesses/Infections/Diseases? Describe. *
Vaccine History *
Basic Antibiotic History *
Please Explain Any Allergies or Sensitivities (Including Foods) *
Food Intolerances? Describe. *
Other Concerns or Goals *
Any Digestive Problems? (eg: constipation, diarrhea, gas) Describe. *
Please list any major medical details you care to mention for each of the following individuals.
Child's Mother *
Child's Father *
Child's Siblings
Child's Maternal Grandmother
Child's Maternal Grandfather
Child's Paternal Grandmother
Child's Paternal Grandfather
Child's Other Relatives
Anything Else You Would Like to Share About Yourself or Your Child?
We understand and appreciate the effort and amount of time you took to fill out the questionnaires. Please allow 2 to 3 business days for us to get back to you and schedule an initial consultation.
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