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Phone: (407) 280-3776
Fax: (407) 517-4358
info@orlandochildrenstherapy.com
www.OrlandoChildrensTherapy.com

Notice of Protected Health Information Privacy Practices

Generalized Consent for Treatment

 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

PLEASE REVIEW IT CAREFULLY.

When I refer to “you” or “your” below, it represents your child or the patient receiving services from Orlando Children's Therapy and Tried-N-True Occupational Therapy INC.  The initials OCT are used to represent Orlando Children's Therapy and Tried-N-True Occupational Therapy INC.

As part of the healthcare service you receive from Orlando Children's Therapy and Tried-N-True Occupational Therapy INC, health records are generated and maintained describing your child’s care including, but not limited to, your name, address, phone number, social security number, health history, symptoms, examination and test results, diagnoses, procedures, treatments, and plans for future care or treatment. This information is called “Protected Health Information” (PHI). This Notice of Privacy Practices describes how Orlando Children's Therapy and Tried-N-True Occupational Therapy INC may use and disclose your information and the rights that you have regarding your health information.

Uses and Disclosures of Health Information Without Authorization

When you obtain services from Orlando Children's Therapy and Tried-N-True Occupational Therapy INC, certain uses and disclosures of your health information are necessary and permitted by law in order to treat you, to process payments for your treatment, and to support the operations of the entity and other involved providers. The following categories describe ways that we use or disclose your information, and some representative examples are provided in each category. All of the ways your health information is used or disclosed should fall within one of these categories.

Your health information will be used for treatment: For example: Disclosure of medical information about you may be made to therapists, doctors, nurses, technicians, or others who are involved in treating you. This information may be disclosed to other physicians who are treating you or to other healthcare facilities involved in your care. Information may be shared with pharmacies, laboratories, or radiology centers for the coordination of different treatments.  
Your health information will be used for payment: For example: Health information about you may be disclosed so that services provided to you may be billed to an insurance company or a third party for reimbursement of services rendered. Information may be provided to your health plan about treatment you are going to receive in order to obtain prior approval or to determine if your health plan will cover the treatment.  
Your health information will be used for health care operations: For example: This information in your health record may be used to evaluate and improve the quality of the care and services we provide.  

Disclosures Required by Law or Otherwise Allowed Without Authorization or Notification

The following disclosures of health information may be made according to state and federal law without your written authorization or verbal agreement:

When a disclosure is required by federal, state, or local law, judicial or administrative proceedings, or for law enforcement; examples would be reporting gunshot wound or child abuse, or responding to court orders
For public health purposes, such as reporting information about births, deaths, and various diseases, or disclosures to the FDA regarding adverse events related to food, medications, or devices
For health oversight activities, such as audits, inspections, or licensure investigations
To organ procurement organizations for the purpose of tissue donation and transplant     
To avoid a serious threat to the health or safety of a person or the public
Contacting you to provide appointment reminders or to recommend treatment alternatives
Notifying you of health-related benefits and services that may be of interest to you

Required Uses and Disclosures: Under the law, we must make disclosures when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with federal privacy law.

Uses and Disclosures Requiring Authorization

Any other uses or disclosures of your health information not addressed in this Notice or otherwise required by law will be made only with your written authorization. You may revoke such authorization at any time.

YOUR INDIVIDUAL RIGHTS UNDER HIPAA

You have the right to request restrictions on certain uses and disclosures of your Protected Health Information. For example, you may wish to restrict your employer from knowing about a medical condition. Regardless of your request, please know that the HIPAA rules allow our office to share your Protected Health Information with the Covered Entities.  If you wish to restrict your PHI please make this request in writing to OCT and discuss with your therapist.
You have the right to receive your Protected Health Information in a confidential communication from our office, such as the US mail.  If you have a specific request for communication please discuss this with your therapist or Amy Vaughn, OCT owner.
You have the right to inspect and copy your Protected Health Information. Copies of your Protected Health Information are available for a reasonable fee paid to our office to cover our expenses of reproducing them.  You may request this information at any time via your therapist, the office manager, or Amy Vaughn, OCT owner.
You have the right to request that we amend your Protected Health Information. In some cases, we may require that these requests be in writing and be supported by a reason for the change. Generally, this will not apply to such routine changes as address or phone number listings.
You have the right to receive, upon request, an accounting of your Protected Health Information that we have provided to Non-Covered entities.
If you have read and responded to this notice through electronic media such as our website or email, you have the right to receive a paper copy of this notice upon request.

If you would like to exercises any of these rights, please contact Amy Vaughn (OCT owner) at (407) 205-7377 and we will make any necessary arrangements for you.

Orlando Children's Therapy and Tried-N-True Occupational Therapy INC is required by law to maintain the privacy of your Protected Health Information and to provide you with this notice of our legal duties and privacy practices as they apply to your Protected Health Information. We are also required to abide by the terms of this notice, which is currently in effect as of December 15, 2012. 

In the future, we reserve the right to change the terms contained in this notice and make any new provisions effective for all of the Protected Health Information we maintain. In the event we elect to change the terms of this notice, a new notice will be posted in our office. In addition, you may receive notification by direct mail, email, or other such communication as our practice may implement from time to time.      

Should you ever believe your privacy rights have been violated, we request you to file a complaint with our office by contacting us at (407) 654-5455 or by mail to: 409 East Oakland Avenue, Suite B, Oakland, FL 34787. You may also register your complaint with the Secretary of the US Department of Health and Human Services, Office of Civil Rights. As part of our commitment to you, we value your privacy and take every precaution in our practice to preserve your right to that privacy. Any complaint you file will be used strictly to improve our operating procedures and in no way will you be retaliated against for filing a complaint.            

Should you have any questions or concerns, please contact OCT owner, Amy Vaughn, directly at (407) 654-5455 to obtain further information.

Generalized Consent for Treatment

I have read and understand the Notice of Protected Health Information Privacy Practices for Orlando Children's Therapy and Tried-N-True Occupational Therapy INC.  I understand that if I do not sign this consent form my child cannot be evaluated or treated by Orlando Children's Therapy and Tried-N-True Occupational Therapy INC.

When Orlando Children's Therapy and Tried-N-True Occupational Therapy INC examines, diagnoses, treats, or refers your child, we will be collecting what the law calls Protected Health Information (PHI) about your child.  We need to use this information to decide on what treatment is best for your child, provide treatment to your child, and collect payment. We may also share this information with others who provide treatment to your child or need it to arrange payment for your child’s treatment or for other business or government functions. 

By checking below you are agreeing to let me use your child’s Protected Health Information (PHI) for the purposes of payment, treatment, and health care operations.  You are also agreeing to allow communications via email, text messages, voice mail and telephone, which may contain your child’s PHI.

I Agree
 

Payment Agreement

At Orlando Children's Therapy and Tried-N-True Occupational Therapy INC we are committed to providing your child with the utmost in quality rehabilitative services.  In order to maintain this level of standard practice, timely payment must be received for services rendered.  Payment is expected at the time of service unless other arrangements have been made in advance, or we are attempting to bill your insurance company.  Please note that insurance coverage does not guarantee payment for occupational therapy services rendered.   If your insurance company denies payment for any reason, you will be billed the contracted rate.

For Privately Paying Patients: Payment will be due at the time of service according to our current rate schedule.


For Patients With In-Network Insurance and Medicaid: 

Proof of insurance is required prior to your first appointment so that we may gather benefit information and obtain prior authorization if required to do so by your carrier.

Any co-pays and/or deductibles are expected at the time of service.  This is legally required as per your contract with the insurance company.  

We will submit therapy claims on your behalf, but please note this is not a guarantee of payment.  If your insurance company denies part, or all, of the therapy claim, you will be billed at the contracted rate for your carrier.  

We will make reasonable effort to assist you in collecting payment from your insurance carrier.  If your insurance company requires submission of information from you directly, you will be expected to do so in a timely manner.  Claims that remain unpaid after 60 days will be billed to you directly.  

Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.  If you have questions about your insurance benefits, please contact your carrier directly.  We will happy to provide you with any necessary procedure and diagnosis codes they may require to answer your questions.
 

For Patients With Out-of-Network Insurance:

Payment is due at the time of service using our current rate schedule. 
We can provide you (upon request) with a receipt/ invoice containing proper coding that you can submit directly to your insurance carrier.  
Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.  If you have questions about your insurance benefits, please contact your carrier directly. 

Non‐Payment: Account balances are expected to be paid prior to your next scheduled therapy session unless other payment arrangements have been made with Amy Vaughn, Orlando Children's Therapy and Tried-N-True Occupational Therapy INC, owner.  If your account has not been paid in full within 15 days, therapy will be put on hold until payment has been made.  If your account has not been paid within 30 days, a late charge of $25.00 will be applied to your account balance, and every subsequent 30 days thereafter.  In the event that we turn this matter over to a collection agency or to an attorney, all fees and costs incurred will be your responsibility.

No-Show / Missed Appointment Fees: While we strive for regular attendance, we understand that children get sick and situations arise which will result in the need to cancel your appointment.  Please do us the courtesy of giving us as much notice as is possible.  Sessions canceled within 2 hours may be subject to a no-call / no-show fee.  Sessions missed without notification will be billed the no-call / no-show fee of $25.00.  Payment for this fee will be required prior to your next scheduled therapy session.  

I read, understand, and agree to comply with the Payment Agreement of Orlando Children's Therapy and Tried-N-True Occupational Therapy INC.

I Agree
 

Attendance Agreement

At Orlando Children's Therapy and Tried-N-True Occupational Therapy INC we are committed to providing your child with the utmost in quality rehabilitative services.  In order to maintain this level of standard practice, regular attendance is essential.  Progress can only occur when children attend their sessions regularly and home carryover is completed.

1) If a client seen in-home, at their school, daycare, or in the office is not able to receive their therapy session, the parent/caregiver is required to call the treating therapist at least 2 hours before the appointment time to cancel the session.  Failure to meet this requirement will result in an unexcused absence.  

2) Unexcused Absence: If the client is not present at the time of the therapist's arrival to your child's home, school, or daycare, is not present at the office within 10 minutes after their scheduled appointment time, or you cancelled less than 2 hours before their scheduled session, this results in an unexcused absence.

3) After three (3) unexcused absences, the client's therapy services will be permanently discharged.     

4) I acknowledge that Orlando Children's Therapy requests a commitment of at least 75% attendance for the month.  I understand that if my child's attendance for the month drops below this, even for excused absences, that they may lose their scheduled time slow for therapy services.

These procedures have been implemented with the purpose of providing consistent and high quality services for your child.  I have read the attendance policy and agree to abide by the conditions stated.

I Agree
 

First Patient's Name

First Name*

Last Name*
First Patient's Date of Birth*
I certify that I am 18 years of age or older
First Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Case History and Background Information

Referring Provider's (Peditrician's) Name & Phone Number *

Family History


Language(s) spoken in the home: *

Parent 1 Full Name: *

Parent 1 Date of Birth:

E-mail address: *

Primary phone: *

Secondary phone:

Parent 2 Full Name:

Parent 2 Date of Birth:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

What are your concerns and reasons for seeking a therapy evaluation? *

Pregnancy and Delivery

Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *
Check any conditions that apply to child during the few weeks following birth:
Anoxia (lack of oxygen)
Jaundice
Swallowing/Feeding Difficulties
Seizures

Health & Medical History


List any significant medical history (i.e. surgeries, ear infections, etc.): *

List current Diagnoses:

Allergies: *

List all current medications: *
Does your child have a history of frequent ear infections?*
No
Yes
If yes, has your child had tubes?*
No
Yes
Has your child had a hearing test?*
No
Yes

If yes, what were the results?
Has your child had a vision exam?*
No
Yes

If yes, what were the results?

Has (or does) your child participated in speech/language therapy, occupational therapy, or physical therapy? If so, when and where were services provided?

Developmental Milestones

Please indicate whether the following milestones were achieved within the specified times:

Sat up (6-8 months)*
No
Yes
Crawled/crept (7-10 months)*
No
Yes
Walked Unaided (12-15 months)*
No
Yes
Babbling (9-12 months)*
No
Yes
First Words (12-15 months)*
No
Yes
Had 50-word vocabulary & combined 2-words (24 months)*
No
Yes
Fed himself/herself (2 1/2- 3 years)*
No
Yes
Achieved daytime bladder control (2-3 years)*
No
Yes
Achieved nighttime bladder control (2 1/2- 4 years)*
No
Yes
Cut with scissors (3- 3 1/2 years)*
No
Yes
What is your child's primary method of communication*
Does your child have difficulty with certain textures or temperatures of food?*
No
Yes

If yes, please explain
Is he/she a messy eater?*
No
Yes

Self-Care

Please check skills your child does regularly: *
drinks from open cup
drinks from straw
finger feeds
ties shoes
buttons & unbuttons pants
eats with a fork
takes off clothing
eats with a spoon
brushes own teeth
puts on clothing
puts on socks & shoes
removes socks & shoes
buttons & unbuttons shirts

Sensory Processing and Behavior

Check characteristics your child CURRENTLY displays. Make notes about behaviors that were significant in the past but have been overcome. *
appears UNaware of objects
appears UNaware of people
makes brief/limited eye contact
displays uncooperative behavior
accepts limits
described as friendly
eats limited foods
appears aware of objects
appears aware of people
makes consistent eye contact
displays cooperative behavior
separates easily
tantrums frequently
covers ears (i.e. loud noises)
playful
described as calm
has difficulty calming
bangs head
rocks
sways
flaps hands
displays aggression
follows directions

Notes:
Sleep Patterns:*
Does he/she sleep through the night?*
No
Yes
Activity Level:*
Distressed by: *
Hair cutting
Tooth brusing
Face washing
None

Please list any equipment you have in the home (i.e. assistive devices, braces, splints, communication equipment, etc.):

Social & Academic Development


Name of child's school: *

How well does your child interact and get along with other children? *

Describe concerns about your child's academic achievement: *

Describe any concerns you have about your child's behavior: *

List children's interests: *

Any additional comments or questions?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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