Child's Name (last, first) *

Child's date of birth *

Child's Age *

Child's Sex

Home Address (street, city, state, zipcode) *

Parent/Guardian Name (last, first) *

Parent/Guardian preferred contact phone: *

Parent/Guardian preferred email (personal/private email recommended): *

Child's Primary Physician (referring physician, if applicable) *

Primary Physician address/phone *

Child's Diagnosis *

What are your primary areas of concern? What are you hoping for the therapist to address? *

What are your goals for therapy? *

Does the child ever complain of pain? If so, where? Please describe:

Please list any medical precautions/allergies: *

Medications: *

Is your child receiving any other services?

What (if any) special equipment does your child use?

Please list any significant illnesses, hospitalizations, surgeries, etc. *

Does your child have a history of: