CNS Hickory - Sensory & Developmental History
Children's Neurotherapy Services, LLC
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If you would prefer to complete a paper copy of this form please contact our office at (828) 267-1688 Hickory Clinic 
Patient/Child's First & Last Name *
Patient Date of Birth
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Mother's Name
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Father's Name
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Child's Primary Care Doctor
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Email Address
School Attending and grade
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Does your child have an Individualized Education Plan (IEP) or 504 Plan at school? 
A copy of your child’s IEP or 504 Plan is needed on the day of the evaluation.   
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