Home
ABOUT
ASSESSMENT
THERAPY
Yoga (Teens)
FEES
FIND US
Home
ABOUT
ASSESSMENT
THERAPY
Yoga (Teens)
FEES
FIND US
Assessment and Therapy
DESCRIPTIVE INFORMATION
Name
*
First Name
Last Name
Gender
Female
Male
Birth Date
MM
DD
YYYY
Phone
(###)
###
####
Email Address
*
Name/relationship of emergency contact
PRESENTING ISSUE
Why do you want your child evaluated?
What are your current concerns regarding your child?
Please check all that apply:
language difficulties
academic difficulties
temper tantrums
biting
hitting
self-injury
sleep problems
sleeps in parents’ bed
has nightmares
nervousness
argumentative
easily distracted
self-help skills
inattentive
school adjustment
motor skills
depressed or anxious
self-stimulatory behaviours: rocking
spinning
flapping hands
other
Please provide details of any items checked above:
HEALTH INFORMATION
Does your child have vision problems?
Yes
No
If Yes, please describe
Does your child wear glasses or contact lenses?
Yes
No
Has your child had an eye exam within the last 2 years?
Yes
No
If Yes, when?
Does your child have problems with hearing?
Yes
No
If Yes, when?
Has your child had a hearing test within the last 5 years?
Yes
No
If Yes, please describe
Does your child have allergies or asthma?
Yes
No
Is your child on any medication at this point in time?
Yes
No
If Yes, please identify
(name, for what condition, dosage, for how long)
Has your child ever had a head injury?
Yes
No
If Yes, please specify when?
Has your child ever has any seizures?
Yes
No
If Yes, please specify when?
Is there a history of mental health disorders in the family?
Yes
No
If Yes, please specify what?
Please bring your completed intake form to your first appointment. Thank you for taking the time to fill out this form :)
Thank you!
