Child Intake Form Child's Name * First Name Last Name Parent's Name First Name Last Name Other family members living in the home (name and age): Phone Number (###) ### #### Email Sex Male Female Grade Level Date of Birth MM DD YYYY Medical History Diagnosis (if any): Age of mother at time of child’s birth: Problems during pregnancy? Complications during labor or delivery? How many weeks gestation was the mother when giving birth? Any problems with child in the hospital before coming home? Any other significant medical history? (surgeries, hospitalizations, chronic congestion, feeding difficulties, or ear infections) Any hearing or vision difficulties? Are you receiving any therapy services currently? Has your child ever received any therapy services (occupational, physical, speech, or behavioral therapy services? (Clinic or school based services) Intake Form How would you describe your child? What are your child’s strengths? What are your child’s weaknesses? What kinds of interests and activities does your child have? (hobbies, sports, clubs)? 5. Please add any other comments you might have regarding your child’s behavior and character: Primary Concerns What are your concerns for your child? Academic: Personal: Social: Motor: Sensory: Behavioral: Self-care: Communication: What are your main concerns for your child’s well-being and development right now? Also, list concerns related to current disruptions in your family system or routines. Parental Goals What are your goals for your child’s program? Please be as specific as possible. Are there any specific challenges you have overcome with your child in the past related to your current concerns? What strategies have you utilized that have worked with your child? Thank you!
