Client Profile Form

    NEW CLIENT PROFILE

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    *Referred by:

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    *Mother's age at birth of child:

    *Father's age at birth of child:

    Prolonged labor Length: Full term  
    Medication during labor Medications: Premature Weeks early:
    Vaginal birth   Parent's length of stay in hospital Days:
    Cesarean birth (emergency) Due to: Baby's weight LBS | OZ:
    Cesarean birth (planned)   Baby's APGAR scores if known Score:

    Jaundice   Intubation How long?
    Transfusion Reason: Retinotherapy (ROP)  
    Hemmorrhage (IVH) Grade: Breathing difficulty  
    Feeding difficulties: Describe: Baby's length of stay at hospital Days:
        Other Describe:

    *Check behaviors which describe your child as an infant: (only one is obligatory)

    Cried a lot, fussy irritable Liked being held Resisted being held Irregular sleep patterns
    Non-demanding Tense when held Very active Happy/content
    Alert Floppy when held Quiet or passive Drooled excessively
    Other

    *Give ages as near as possible when your child: (if not applicable, write "N/A")

    Bottle: how long? * Crawled? * Spoke simple words: *
    Breast: how long? * Cruised: * Spoke in sentences: *
    Rolled over: * Walked: * Potty trained: *
    Sat unsupported: *

    Allergies
    Anemia
    Chicken Pox
    Diabetes
    Ear Infections
    Epilepsy/Seizures
    Hearing Testing
    Heart Trouble
    High Temperatures
    Measles
    Meningitis
    Mumps
    Scarlet Fever
    Vision Testing
    Whooping Cough
    Surgeries
    Physical Injuries
    None

    Adaptive stroller Supplemental oxygen Gait trainer
    Adaptive toilet chair Wheelchair Arm/hand braces
    Apnea monitor Adaptive bath chair Leg/foot braces
    Heart monitor Stander PECS
    Tube fed Walker Communication device
    Adaptive chair (describe)  

    Applied Behavioral Analysis
    Discrete Trials (DTT)
    Early intervention school
    Feeding therapy
    Floortime
    Hippotherapy
    Infant stimulation teacher
    Mobility specialist
    Occupational therapy
    Physical therapy
    Speech therapy
    Therapeutic horse riding
    Vision specialist
    Other
    None    

    *What aspect(s) of the day or daily routine is (are) the most difficult for your child? Why?

    *What strategies do you find effective for calming your child when he/she becomes upset?

    *Describe how your child transitions between new and familiar people?

    *Describe how your child transitions between new and familiar environments?

    *Describe your child’s leisure activities:

    List what your child usually does during these hours?

    Teacher: School:
    Grade level: Type of Classroom:
    1:1 instructional assistant Resource assistant

    Relationship with teacher:

    Relationship with classmates:

    Area of academic difficulty:

    Area of most success or enjoyment:

    Safety and independence in accessing the school environment:


    Please sign below.