Parent Intake Form

I. Identifying Information

Date

Enter today's date/date of submitting this form

YYYY

Name of Child

First Name

Last Name

Child's Sex

Child's Age

Date of Birth

YYYY

School

Current Grade

Pediatrician

Pediatrician Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pediatrician Contact Number

(###)

###

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Mother's Name

First Name

Last Name

Mother's Age

Mother's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Home Phone

(###)

###

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Mother's Business Phone

(###)

###

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Mother's Cell Phone

(###)

###

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Mother's Occupation

Father's Name

First Name

Last Name

Father's Age

Father's Address

If different than mother's address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Home Phone

(###)

###

####

Father's Business Phone

(###)

###

####

Father's Cell Phone

(###)

###

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Father's Occupation

Siblings

Please list the names, ages, and dates-of birth of the client’s (your child’s) siblings:

II. Reasons for Referral

Primary Concern:

Other Concerns:

III. Prenatal History

Complications

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)?

How old were you when your child was born?

Were any of the following taken during pregnancy?

Beer, Wine, or Alcohol

Coffee/Caffeine

Prescription Medications

Over-the-counter and/or herbal products

Were there complications related to your child’s delivery?

What was your child's birth weight?

Apgar Score:

Were there any health complications following birth? If yes, please specify:

IV. Postnatal Period and Infancy

Were there early infancy feeding problems?

Was the child colicky?

Were there early infancy sleep pattern difficulties?

Were there any problems with the infant’s responsiveness (alertness)?

Did the child experience any health problems during infancy?

How active was your child as an infant?

V. Developmental Milestones

At what age did (s)he sit up?

At what age did (s)he crawl?

At what age did (s)he walk?

At what age did (s)he speak single words (other than mama or dada)?

At what age did (s)he string two or more words together?

At what age was (s)he toilet-trained? (bladder control)?

At what age was (s)he toilet-trained? (bowel control)

Approximately how much time did toilet training take from onset to completion?

VI. Medical History

How is his/her hearing?

How is his/her vision? Is he/she colorblind?

How is his/her gross (large) motor coordination?

How is his/her fine (small) motor coordination?

How is his/her speech, articulation, and language processing?

Chronic Health Problems:

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:

Head Injury

Coma

Convulsions

Persistent High Fevers

Do you know or suspect that your child may be using nonprescription medications and/or alcohol?

Is there any history of physical or sexual abuse?

Does your child have difficulty sleeping at night? If so, what kind of difficult?

Does your child have any difficulties with eating or, more generally, with his/her appetite?

VII. Educational and Learning Concerns

How is your child performing at school at the present time with regard to reading, math and other academic skills?

To the best of your knowledge, at what grade level is your child functioning in reading and mathematics?

Does your child complete assignments in a timely, organized fashion?

Does he/she understand and follow directions?

Is he/she generally attentive and focused in class?

Has your child ever had to repeat a grade?

Is he or she receiving any educational support services either in or outside of school? If so, please specify:

Briefly describe your child’s experiences in Preschool:

Briefly describe your child’s experiences in Elementary School:

Briefly describe your child’s experiences in Middle School:

Briefly describe your child’s experiences in High School:

Have your child’s teacher’s expressed concerns about him/her?

VIII. Peer Relationships

How does your child get along with his/her siblings?

Does your child seek friendships with peers?

Is your child sought out by peers?

Does your child prefer to play with children who are approximately of the same age?

Briefly describe any concerns about peer-related problems.

IX. Psychiatric History

Has your child ever evidenced difficulties in one or more of the following areas: Mood (i.e., sadness or elation), Anxiety, Impulsivity/Hyperactivity, Aggression, and/or Judgment?

Have you ever consulted with a mental health professional about your child? If so, please specify why:

Has your child ever been evaluated by a psychiatrist or psychologist? If so, briefly describe the findings:

Has medication ever been prescribed for psychiatric, behavioral, attentional, or learning purposes? If so, what medications and when?

Is there any family history of psychiatric, neurological, and/or learning disabilities in your extended family? (Please focus on first degree relatives—brothers, sisters, grandparents, etc.).

X. Other Concerns/Issues

Please elaborate: