TLC Family Information Form
Names of Parent(s): *
Child's Name: *
Child's Date of Birth: *
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Child's age in years & months: *
Was your child born prematurely? *
Child's gender: *
Best Phone Number: *
Alternative Phone Number: *
Email Address: *
Names and ages of siblings:
Child's Medical History: *
Does the child receive childcare, attend nursery/preschool, or attend school? *
Please describe your primary concern/question: *
Have there been any recent significant changes in your child's life? If so, please describe: *
Have you contacted your pediatrician about your concern?
Have you contacted other pediatric professionals?
Please list all resource books, websites, and/or centers you have already contacted:
Please list any concerns around your child's development (e.g. physical, language, cognitive, social/emotional):
Please describe your child's eating and sleeping habits:
Has your child received a formal diagnosis?
Please include any helpful information here:
Have you received one-on-one support from a TLC professional previously? If yes, please provide the name of the professional. *
Do you prefer a morning, afternoon, or evening session? Which days of the week would work best with your schedule? *
Do you prefer a phone call or zoom session? *
How did you hear about The Loved Child, LLC?
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