New Client Intake Form (0 - 6 months)

*Required fields are noted with an asterisk.

Patient Name

First Name

Last Name

Sex

Female

Male

Age/Date of Birth *

Parents'/Guardians' Names

Address *

Phone

(###)

###

####

Referring physician

PCP (if different)

Specialists (Name and specialty)

Family Information

Language(s) spoken in home

Names and ages of siblings

Parents'/Guardians' main concern *

Medical History *

Were there any complications during pregnancy?

Were there any complications during or just after birth?

What was your child's birth weight?

Did/does your baby suffer from any of the following:

Ear infections

GERD (gastroesophageal reflux disease)

Tonsillectomy/adenoidectomy

Seizures

Restrictive diet

Hearing problems

Vision problems

Please list any ER visits and/or overnight hospitalizations

Please list any surgeries

Please list any previous injuries

Please list any prescription medications

Please list any allergies

Other

Please describe your baby's current health

At approximately what age did your baby... (if relevant) *

Tolerate tummy time

Hold her/his head up unsupported

Roll front to back

Roll back to front

Sit with support

Sit independently

Commando crawl

Crawl reciprocally

Does your baby have a preferred position of her/his head or body?

Communication, eat, sleep *

How does your baby indicate what he/she wants?

Does your baby babble or vocalize?

How are your baby's sleeping habits?

How are your baby's feeding/nursing habits?

Do you have any concerns about your baby's self-regulation skills?

Please list any other information you would like me to know.

I certify that this information is true and correct to the best of my knowledge. I will notify my therapist of any changes in the above information within 30 days.

Name

Date

YYYY

Relationship to patient