Diagnostic Evaluation Intake Form SectionsGuardian InformationPediatrician InformationEmergency ContactsFamily HistoryPurpose of EvaluationMedical HistoryDevelopment HistoryEducation HistoryLanguage SkillsSocial SkillsBehavioral/Social History You have the option to save and continue if you do not finish the full form in one sitting. To save your form, click 'Save and Continue Later' at the bottom of the form next to 'Submit.' Child Name* First Name Last Name Child Date of Birth* MM slash DD slash YYYY Child Gender* Female Male Name of person completing this form and relationship to child* Guardian InformationGuardian 1 Name* First Name Last Name Guardian 1 Email* Guardian 1 Phone Number*Preferred method of contact* Email Text Phone Any of the above Guardian 2 (if applicable) First Name Last Name Guardian 2 Email Guardian 2 Phone NumberPreferred method of contact Email Text Phone Any of the above Guardian 3 (if applicable) First Name Last Name Guardian 3 Email Guardian 3 Phone NumberPreferred method of contact Email Text Phone Any of the above Name(s) of guardian(s) with custody* Status of parents' marriage* Married Separated Divorced Single Widowed If parents are divorced, please indicate whether there are step parents Stepmother Stepfather Child is living at home with:* Both parents Mother Father Legal guardian Other If you selected 'other,' please describe. Pediatrician InformationName* First Name Last Name Name of Practice/Group PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactsEmergency Contacts*NamePhone NumberRelationship Family History & Background InformationDoes your child have siblings?* Yes No If yes, list the names and ages of siblings belowSibling NameSibling AgeDo they live in the home? (yes or no) Primary language(s) spoken at home* If other languages are spoken at home, please describe.Considerations for treatment* Cultural Legal Spiritual Other None of the above If you checked 'yes' to any of the above considerations, please provide any information you think would be helpful for us to know for treatment.Is there a history in the immediate or extended family of the following, and if so who? ADD/ADHD Autism Language delays Verbal apraxia Migraines Compulsive behaviors Obsessive behaviors Anxiety Depression Bipolar disorder Schizophrenia Tics Learning disabilities Intellectual disabilities Social difficulties Down syndrome Epilepsy Cerebral palsy Seizures Heart Disease Other ADD/AHD ExplanationAutism ExplanationLanguage Delays ExplanationVerbal Apraxia ExplanationMigraines ExplanationCompulsive Behaviors ExplanationObsessive Behaviors ExplanationAnxiety ExplanationDepression ExplanationBipolar Disorder ExplanationSchizophrenia ExplanationTics ExplanationLearning Disabilities ExplanationIntellectual Disabilities ExplanationSocial Difficulties ExplanationDown Syndrome ExplanationEpilepsy ExplanationCerebral Palsy ExplanationSeizures ExplanationHeart Disease ExplanationOther ExplanationPurpose of EvaluationWhat are your current concerns?*Describe your child's current level of speech and language.*Has your child ever received any of the following services?* Speech therapy Occupational therapy Physical therapy Developmental therapy Other None of the above If yes, please describe below.If your child is currently receiving services, please list providers below.Provider NameType of ServiceApproximate start date Does your child have any current (or past) diagnoses?* Yes No If yes, please describe and provide the date of diagnosis.Child Medical HistoryBirth history: gestation weeks* Birth Weight* Delivery* Vaginal C-section Breech Induced Complications during pregnancy or delivery (if any)* Medications taken during pregnancy or delivery (if any)* Was your child adopted?* Yes No Was your child conceived using artificial reproductive technology?* Yes No Did your child experience any infant illnesses or complications?* Yes No Does your child have any allergies?* Yes No Infant Illnesses or Complications Explanation Allergies Explanation Has your child had any surgeries or hospitalizations?* Yes No Has your child ever had ear infections or tubes?* Yes No Surgeries or Hospitalizations, please describe and provide dates. Ear Infections or Tubes, please describe and provide dates. Has your child experienced hearing or vision problems?* Yes No Does your child currently take any medications?* Yes No Vision or Hearing Problems, please describe. If your child is currently taking any medications, list all below.Name of medicationDosage/frequencyStart date of medication Describe any special dietary considerations.*Child Developmental HistoryList milestones (in months) below.Age (in months) when your child said their first word*Please enter a number greater than or equal to 0.MonthsAge (in months) when your child took their first steps*Please enter a number greater than or equal to 0.MonthsAge (in months) when your child started imitating simple gestures (e.g., clapping, waving)*Please enter a number greater than or equal to 0.MonthsAge (in months) when your child started imitating simple gestures using objects (e.g., banging on a drum)*Please enter a number greater than or equal to 0.MonthsDescribe your child's general gross motor abilities.*Describe your child's general fine motor abilities.*Describe any past/current concerns with feeding or eating.*Describe your child's current activity level.*Describe any concerns you have with your child's development.*Child Educational HistorySchool(s) attended (if applicable)Name of schoolAges/grades attendedOther notes Describe any pre-academic concerns.*Describe any learning concerns.*Describe any 504-Plans/IEPs (past and current).*Current Language SkillsDescribe your child's current eye contact.*Describe your child's current non-verbal communication (e.g., gestures).*Describe your child's current responsiveness to directions.*Describe any repetitive behaviors.*Describe your child's ability to initiate and maintain conversations.*Social SkillsDoes your child have difficulty playing with peers?* Yes No Does your child have difficulty getting along with children who are their age?* Yes No Does your child prefer to play alone?* Yes No Does your child prefer younger or older peers?* Yes No Does your child engage in imaginative and creative play?* Yes No Does your child engage in self-stimulating behavior?* Yes No Behavioral/Social HistoryDescribe current behavior concerns.*Describe triggers for challenging behaviors.*Describe situations when challenging behaviors frequently occur.*Describe places where challenging behaviors frequently occur.*Describe disciplines/interventions used when challenging behaviors occur.*Has your child experienced or witnessed physical, sexual, or emotional abuse?* Yes No Describe any current family stressors.*What is motivating for your child? (e.g., stickers, token system)*Please provide any other information that you think would be helpful for us to know (e.g., challenging behaviors, elopement).*ConfirmationI affirm that the above information is a complete and true statement of all facts and circumstances relative to my child.Parent/Legal Guardian* First Name Last Name Today's Date* MM slash DD slash YYYY Guardian Signature*
