Client Profile Form

    NEW CLIENT PROFILE



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    *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







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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?

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    Crawled?

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    Spoke simple words:

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    Breast: how long?

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    Cruised:

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    Spoke in sentences:

    *

    Rolled over:

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    Walked:

    *

    Potty trained:

    *

    Sat unsupported:

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    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.