TLC Family Information Form
Names of Parent(s): *
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Child's Name: *
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Child's Date of Birth: *
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DD
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YYYY
Child's age in years & months: *
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Was your child born prematurely? *
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Child's gender: *
Best Phone Number: *
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Alternative Phone Number: *
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Email Address: *
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Names and ages of siblings:
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Child's Medical History: *
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Does the child receive childcare and/or attend school? *
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Please describe your primary concern/question: *
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Have there been any recent significant changes in your child's life? If so, please describe: *
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Have you contacted your pediatrician about your concern?
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Have you contacted other pediatric professionals?
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Please list all resource books, websites, and/or centers you have already contacted:
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Please list any concerns around your child's development (e.g. physical, language, cognitive, social/emotional):
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Please describe your child's eating and sleeping habits:
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Has your child received a formal diagnosis?
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Please include any helpful information here:
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Do you prefer a morning, afternoon, or evening consultation?
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