CLIENT INFORMATION AND HISTORY FORM 2-2025

CLIENT INFORMATION AND HISTORY FORM
FAMILY INFORMATION
Todays Date

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
Age
Parent 1 Name and Relationship
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Age
Occupation
Education
Parent 2 Name and Relationship
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Age
Occupation
Education
Sibling Name 1
Age
School/Grade
Any Developmental Concerns?
Sibling Name 2
Age
School/Grade
Any Developmental Concerns?
Sibling Name 3
Age
School/Grade
Any Developmental Concerns?
Please list those who live with your child.
Please list other people who spend time with your child (examples: babysitters, relatives, friends):
Name
Relationship
CLIENT INFORMATION
Briefly describe your concerns regarding your child:

0/120
Briefly describe your child’s strengths:

0/120
Please list any therapeutic equipment your child has (include braces, etc.)

0/50
Is there a family history of developmental disorders?

YesNo
Please explain:

0/100
Are there any other languages spoken at home besides English?
BIRTH HISTORY
Check which is applicable. This is our

BiologicalFosterAdopted child
Were there any problems or hospitalizations during the pregnancy with this child?

0/80
Were any prescription or nonprescription medication used during this pregnancy?

0/80

	Yes	No
Was your child premature?
Were there complications with the delivery?
Was the birth by C-section?

Birth weight:
Born at how many weeks gestation:
Was the mother given any drugs during labor and delivery?

YesNo
Were there any birth injuries?

YesNo
Did your child receive medication/treatment at birth?

YesNo
Please provide further explanation for the above answers:

0/80
MEDICAL HISTORY
The child's current health is

GoodFairPoor
Please list all current medications being taken by your child.
Medication

0/60
Dosage

0/60
Reason for Medication

0/60
Does the child have a specific diagnosis:

YesNo
If so, please describe:

0/60
Does the child have a history of hospitalizations?

YesNo
Does or did your child ever have any health problems/surgeries outside of those common to childhood?

YesNo
Does your child have a history of ear infections/PE Tubes?

YesNo
Please explain any “yes” answers:

0/100
Has your child's hearing been tested?

YesNo
Results of hearing tests:

0/60
Please list any allergies (medicines, food, environmental):

0/100
DEVELOPMENTAL HISTORY

Milestones - at approximately what age did your child:
Roll over
Babble or coo
Sit alone
Say first words
Creep or crawl
Speak in sentences/combine words
Cruise or walk with support
Undress self
Walk alone
Dress self
Run
Climb stairs
Feeding
Breast or bottle fed?

0/4
If breast fed, for how long?

0/10
Did your child have feeding or swallowing problems in infancy?

YesNo
If so, please describe:

0/30
Is your child a picky eater?

YesNo
Please list foods that your child typically will eat:

0/80
What does your child use to drink? (e.g. bottle, sippy cup, etc.)

0/40
Toileting
Is your child toilet trained?

YesNo
If so, at what age was your child trained?
Motor/Sensory

	Yes	No
Does your child seem sensitive to certain sounds?
Does your child seem sensitive to certain closing or textures?
Does your child seem to seek out or avoid certain movements?
Does your child seem clumsy?
Does your child have poor handwriting?

Please explain any “yes” answers:

0/80
Social-Emotional Behavior, Communication
How does your child get along with other children?

0/10
Does your child prefer to play alone or with other children?

0/10
Does your child tend to be easily frustrated?

YesNo
Please explain:

0/40
Please describe how you consequence your child when he or she behaves negatively:

0/30
Please feel free to include comments about your child's behavior

0/30
When you talk to your child, how much does he/she understand? Check all that apply.

A few wordsMany words and phrasesSimple directions (i.e. come here; sit down)Complex directions (i.e. go get a book & bring it to me)QuestionsAlmost everything I say
How does your child usually let you know what he/she wants Check all that apply.*

Points to objectsUses gesturesUses sign languageGruntsMakes a few soundsUses single wordsUses two or three-word phrasesUses long sentencesImitates what I sayRepeats lines from tv shows
What does your child like to talk about?

0/40
EDUCATIONAL HISTORY
Is your child enrolled in a school?

YesNo
Name of school:
Days and hours of school:
Grade:
Teacher:
How does your child do in school?

0/20
Does your child receive any special education services?

YesNo
If yes, please list type and frequency:

0/20
SOCIAL WORK INFORMATION
Are there any community agencies active with your child?

YesNo
Agency name:
Name of case worker:
THERAPY HISTORY
Has your child been previously evaluated for/received therapy services?

YesNo
If yes, where and when?

0/80
Does your child currently receive therapy services elsewhere?

YesNo
If yes, where and when?

0/15
Therapy received

Physical TherapyOccupational TherapySpeech TherapyOther
Frequency of Physical Therapy
Therapist
Frequency of Occupational Therapy
Therapist
Frequency of Speech Therapy
Therapist
Other Frequency
Therapist
ACTIVITY INFORMATION
Describe play activities that your child likes best:

0/100
In our house, we couldn't live without:

0/100
Please describe what you love most about your child:

0/100
Please list some specific goals that you and your family have for your child:

0/100
Additional Comments/Concerns:

0/150
Thank you for taking the time to complete this form.
Name of person(s) completing this history:
Relationship to child:
Date:

MonthDayYear
Date
Should be Empty: