About
- Background
- Approach
Services
Forms
Contact

Alexandra Buwalda DPT, PCS

About
- Background
- Approach
Services
Forms
Contact

New Client Intake Form (6 - 18 months)

New Client Intake Form (6 - 18 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

Email *

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 child suffer from any of the following:

Chronic ear infections

Ear tubes

Childhood illnesses (measles, mumps, chicken pox)

Frequent strep throat

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

Is your child vaccinated following CDC guidelines?

Yes

No

If not, please explain

Motor milestones (if applicable). At approximately what age did your child:

Roll independently

Sit independently

Commando crawl

Crawl reciprocally

Pull up to stand

Stand independently

Walk independently

Communication

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 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 *

MM

DD

YYYY

Relationship to patient *

Thank you for your submission of the intake form.

Please click one of the links below to review and electronically sign the additionally required forms (Consent to Treat, HIPAA Privacy, Cancellation Policy, Communication Policy and either Consent to Treat at Home or Consent to Treat in a Facility).

CONTACT

Alexandra Buwalda, DPT

@ The Gowanus Treehouse
540 President Street, Suite 1E
Brooklyn, NY 11215

Email: alex@alexbuwalda.com
Phone: 917.648.8682
Fax: 718.858.1188