DESCRIPTIVE INFORMATION
Name *
Name
Gender
Birth Date
Birth Date
Phone
Phone
PRESENTING ISSUE
Please check all that apply:
HEALTH INFORMATION
Does your child have vision problems?
Does your child wear glasses or contact lenses?
Has your child had an eye exam within the last 2 years?
Does your child have problems with hearing?
Has your child had a hearing test within the last 5 years?
Does your child have allergies or asthma?
Is your child on any medication at this point in time?
(name, for what condition, dosage, for how long)
Has your child ever had a head injury?
Has your child ever has any seizures?
Is there a history of mental health disorders in the family?
Please bring your completed intake form to your first appointment. Thank you for taking the time to fill out this form :)