Client Profile Form NEW CLIENT PROFILE CHILD'S IDENTIFYING INFORMATION *** *PARENT/CAREGIVER PARENT/CAREGIVER * * * * * * * List names and ages of children in the family: *Referred by: Check which barriers have affected your child’s access to services: LGBTQ+ discrimination Gender discrimination/misgendering Cultural/racial insensitivity in providers Racism in service provision Immigration/documentation status Language barriers Limited cultural awareness in providers Limited mental illness awareness in providers Limited neuro-divergence understanding in providers Limited access to technology Stigma or lack of competence about disability in providers/ableism Limited time for therapy Financial cost of services/limited access to insurance Other N/A *What are your concerns? *When did you first notice your child’s difficulties and how were they apparent to you? *Diagnosis: (if none, write "None") ** *PHYSICIANS (only first one is obligatory) *NAME (List All) *SPECIALTY (neurologist, pediatrician, etc.) *PHONE # * * * *PRENATAL AND BIRTH HISTORY *Mother's age at birth of child: *Father's age at birth of child: *Was mother ill during pregnancy? If yes, explain and give prenatal months: Please respond to or check all that apply: 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: *Neonatal Health: (only one checkbox required) 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: DEVELOPMENTAL HISTORY *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: * Is there anything else you would like us to know about your child's developmental history? *MEDICAL HISTORY (only one is obligatory) *Condition *Age *Describe 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 MEDICATIONS (if none, write "None") Medication What is it for? Side Effects ADAPTIVE EQUIPMENT 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) *SERVICES (only one is obligatory) *Services *Previously or Currently? *Where and with whom? 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 HOME AND COMMUNITY *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? 6 - 8 am 8 am - 12 noon 12 noon - 3 pm 3 – 6 pm 6 pm - bedtime EDUCATIONAL INFORMATION 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: Is there anything else you would like to tell us about your child? Parent/Guardian/Legal Representative of Child* Email Address* (to receive a copy of form) Please sign below. Today's Date*
