For us to provide your child with the best diagnosis and treatment, please give us some background information. If you do not remember an exact date or age, no problem! Just give us an estimate or leave that part blank. This will take about 10 minutes to complete.

Client Information (1 of 2)

Child Information
Child's Name: *
Child's Name:
DOB: *
DOB:
Family Information
Home Address: *
Home Address:
Home Phone (if available) *
Home Phone (if available)
Parent / Guardian 1: *
Parent / Guardian 1:
Address (if different)
Address (if different)
Cell Phone:
Cell Phone:
Work Phone:
Work Phone:
Parent / Guardian 2 Cell Phone:
Parent / Guardian 2 Cell Phone:
Child Details and History
List favorite toys, activities, interests...
Gestures, single words, phrases, sentences?
By you? By family members? By unfamiliar listeners?
Birth | Developmental History
If yes, please state when they were inserted, whether both ears or one, and whether they are currently still in place.
Educational History
Ex: Preschool at Tomorrow's Promise Preschool, two days a week / Day Care at Montgomery Little Bears, 5 days a week
Today's Date
Today's Date