• CHILD CASE HISTORY FORM

    CHILD CASE HISTORY FORM

  • Welcome to Auburn TLC! In order to help us achieve our mission of providing the highest quality treatment for your child, please fill out this form as accurately as possible. We look forward to working with you and your child.

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  • Area(s) of Concern

  • Prenatal and Birth History

  • Medical History

  • Has your child ever experienced any of the following? Check all that apply and please indicate age of occurrence:

     

  • Speech and Language Development

  • Gross Motor Development

    Please indicate the ages when these skills were observed
  • Fine Motor Skills Development

    Please indicate the ages when these skills were observed
  • Education History

  • Behavior

    Please check all that apply to your child
  • Self-Help Skills

  • Social/Emotional Development

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  • Should be Empty: