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Parent Intake Form

I. Identifying Information
Date *
Date
Enter today's date/date of submitting this form
Name of Child *
Name of Child
Date of Birth
Date of Birth
Pediatrician Address
Pediatrician Address
Pediatrician Contact Number
Pediatrician Contact Number
Mother's Name
Mother's Name
Mother's Address
Mother's Address
Mother's Home Phone
Mother's Home Phone
Mother's Business Phone
Mother's Business Phone
Mother's Cell Phone
Mother's Cell Phone
Father's Name
Father's Name
Father's Address
Father's Address
If different than mother's address
Father's Home Phone
Father's Home Phone
Father's Business Phone
Father's Business Phone
Father's Cell Phone
Father's Cell Phone
Please list the names, ages, and dates-of birth of the client’s (your child’s) siblings:
II. Reasons for Referral
III. Prenatal History
Were there any complications during pregnancy and/or delivery (such as hypertension/toxemia/pre-eclampsia and/or eclampsia (seizures), prematurity, maternal Lyme disease, or infection)?
Were any of the following taken during pregnancy?
IV. Postnatal Period and Infancy
V. Developmental Milestones
VI. Medical History
Has he had any chronic health problems (e.g., asthma, allergies, diabetes, heart condition)? If yes, please specify the onset, duration, and any residual problems as a result of the condition:
Has your child had any of the following:
VII. Educational and Learning Concerns
VIII. Peer Relationships
IX. Psychiatric History
X. Other Concerns/Issues