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Case History Form
Consent Form
Attendance Policy
Financial Resposibility Form
Notice of Privacy Practices
Release of Information Form
Photo, Video, Teletherapy Consent Form
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Pediatric Therapy Case History Form
Date
Speech Therapy
Occupational Therapy
Child Information
Child's full name
*
Date of birth
*
Day
Month
Year
Address
*
Age
*
Primary Language
*
Gender
*
Pediatrician
*
Referred by
*
Insurance
*
Primary name on insurance
*
Group Number
*
ID Number
*
Parent/Guardian Information
Name(s)
*
Relationship
*
Email
*
Phone
*
Preferred contact method
*
Phone
Email
Text
Pregnancy and Birth History
Complications
*
Gestational age
*
Weight
*
NICU Stay
*
Medical History
Diagnoses
*
Medications
*
Allergies
*
Vision/hearing testing completed?
*
Yes
No
Family history of developmental concerns or learning challenges:
*
Previous Therapy
*
Current Therapy
*
Daycare/Preschool/Education History
School
*
Educational Service/Support
*
Performance in school
*
Development Milestones
Please specify below
*
Met within expected limits
Not met within expected limits
Rolled
*
Sat unsupported
*
Crawled
*
Walked
*
Toilet trained
*
Fed Self
*
First Words
*
Combined words
*
Current Areas of Concern
Please check any areas of concern and provide a brief explanation in the space below. Additional details may be discussed with your therapist.
*
Fine motor
Gross motor
Self care
Sensory
Feeding
Communication
Speech sound
Behavior
Social
How would you like to see your child improve?
Please share any additional information including strengths, motivators, and interests that would help us best support your child.
Submit
Home
About us
Services
Team
Contact Us
Patient Forms
Case History Form
Consent Form
Attendance Policy
Financial Resposibility Form
Notice of Privacy Practices
Release of Information Form
Photo, Video, Teletherapy Consent Form
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