Contact *

First Name

Last Name

Name of Child

First Name

Last Name

Date of Birth

MM

DD

YYYY

Sex

Male

Female

Father *

First Name

Last Name

Phone *

(###)

###

####

Mother *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Speech and Cognition-Communicates in the Following Ways

Non-Verbal

Non-Verbal but Vocalizes

Says Words

Speaks but Hard to Understand

Sign Language

Electronic Device

Ability to Listen and Follow Directions

Unable to Follow Directions

Limited-Follows Simple One Step Directions

No Issues Following Directions

Other-Please Describe Below

Sensory Concerns

Likes Noises

Does Not Like Noises

Other-Please Describe Below

Mobility

Walks Independently

Wheelchair

Braces

Other-Please Describe Below

Special Food Issues

Liquid Food

Soft Food

Difficulty Swallowing

Daily Life Activities

Toileting

Independant

Diapers

Requires Assistance

Daily Life Activities

Eating

Independant

Requires Assistance

Daily Life Activities

Social Behavioral Issues

Tantrums

Running Away

Yelling

Biting

Hitting

Pushing

Other-Please Describe Below

Person Completing this Form

First Name

Last Name

Date Completing this Form

MM

DD

YYYY

Parent/Caregiver Interview Date

MM

DD

YYYY

Interviewer

First Name

Last Name