Client Profile Form

Client Profile - Step 1 of 10

Today's Date *

CHILD'S IDENTIFYING INFORMATION

Child's Name *

First

Last

Date of Birth *

Age

Child's Pronouns

Custom Pronouns

If the child prefers specific pronouns not listed above, please enter them here.

Next - Parent/Caregiver(s)

PARENT/CAREGIVER(S)

Name *

First

Last

Preferred Pronouns *

Custom Pronouns

If the parent/caregiver prefers specific pronouns not listed above, please enter them here.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Primary *

Phone - Secondary

Email *

Occupation *

Name

First

Last

Preferred Pronouns

Custom Pronouns

If the parent/caregiver prefers specific pronouns not listed above, please enter them here.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Primary

Phone - Secondary

Occupation

List Names and Ages of Children in the Family

Next - Additional Information

ADDITIONAL INFORMATION

Referred by *

Languages of the household(s): *

Check which barriers have affected your child’s access to services:

LGBTQ+ discrimination
Gender discrimination/misgendering
Cultural/racial insensitivity in providers
Racism in service provision
Immigration/documentation status
Language barriers
Limited cultural awareness in providers
Limited mental illness awareness in providers
Limited neuro-divergence understanding in providers
Limited access to technology
Stigma or lack of competence about disability in providers/ableism
Limited time for therapy
Financial cost of services/limited access to insurance
Other
N/A

If "Other" barrier selected above, please explain.

What are your concerns? *

When did you first notice your child’s difficulties and how were they apparent to you? *

What are your child's joys?

What are your child's fears/concerns?

What are your child's strengths?

Next - Diagnosis & Physician Info

DIAGNOSIS & PHYSICIAN INFO

Diagnosis *

Date of Diagnosis *

Diagnosed By *

PHYSICIANS (only first one is required)

Name

Name *

Name

Specialty (neurologist, pediatrician, etc...)

Specialty *

Specialty

Phone

Phone *

Phone

Next - Prenatal and Birth History

PRENATAL AND BIRTH HISTORY

Was mother ill during pregnancy? If yes, explain and give prenatal months: *

Please respond to or check all that apply:

Prolonged Labor Checkbox

Prolonged Labor

Length:

Premature Checkbox

Premature

Weeks early:

Cesarean Birth Checkbox

Cesarean Birth (emergency)

Due to:

Full Term Checkbox

Full Term

Vaginal Birth Checkbox

Vaginal Birth

Cesarean Birth (planned) Checkbox

Cesarean Birth (planned)

Medication During Labor Checkbox

Medication during labor

Medications:

Parents Length of Stay in Hospital Checkbox

Parents Length of Stay in Hospital

Days:

Baby's Weight Checkbox

Baby's Weight

LBS | OZs

Baby's APGAR Scores Checkbox

Baby's APGAR Scores (if known)

Score:

NEONATAL HEALTH

(Only one checkbox required) *

Intubation Checkbox

Intubation

How long?

Hemorrhage (IVH) Checkbox

Hemorrhage (IVH)

Grade:

Jaundice Checkbox

Jaundice

Retinotherapy (ROP) Checkbox

Retinotherapy (ROP)

Other Checkbox

Other

Describe:

Transfusion Checkbox

Transfusion

Reason:

Feeding Difficulties Checkbox

Feeding Difficulties

Describe:

Baby's Length of Stay at Hospital Checkbox

Baby's Length of Stay at Hospital

Days:

Breathing Difficulty Checkbox

Breathing Difficulty

Next - Developmental History

DEVELOPMENTAL HISTORY

Check behaviors which describe your child as an infant: (only one is obligatory) *

Cried a lot, fussy irritable
Liked being held
Resisted being held
Irregular sleep patterns
Non-demanding
Tense when held
Very active
Happy/content
Alert
Floppy when held
Quiet or passive
Drooled excessively
Other

If Other, then describe:

Give ages as near as possible when your child:

If not applicable, please write "N/A"

Bottle: How long? *

Breast: How long? *

Rolled over: *

Sat unsupported: *

Crawled? *

Cruised: *

Walked: *

Spoke simple words: *

Spoke in sentences: *

Potty trained: *

Is there anything else you would like us to know about your child's developmental history?

Next - Medical History

MEDICAL HISTORY

Only one is required *

Condition

Age

Describe

Allergies Checkbox

Allergies

Allergies Age

Allergies Describe

Anemia Checkbox

Anemia

Anemia Age

Anemia Describe

Chicken Pox Checkbox

Chicken Pox

Chicken Pox Age

Chicken Pox Describe

Diabetes Checkbox

Diabetes

Diabetes Age

Diabetes Describe

Ear Infections Checkbox

Ear Infections

Ear Infections Age

Ear Infections Describe

Epilepsy/Seizures Checkbox

Epilepsy/Seizures

Epilepsy/Seizures Age

Epilepsy/Seizures Describe

Hearing Testing Checkbox

Hearing Testing

Hearing Testing Age

Hearing Testing Describe

Heart Trouble Checkbox

Heart Trouble

Heart Trouble Age

Heart Trouble Describe

High Temperatures Checkbox

High Temperatures

High Temperatures Age

High Temperatures Describe

Measles Checkbox

Measles

Measles Age

Measles Describe

Meningitis Checkbox

Meningitis

Meningitis Age

Meningitis Describe

Mumps Checkbox

Mumps

Mumps Age

Mumps Describe

Scarlet Fever Checkbox

Scarlet Fever

Scarlet Fever Age

Scarlet Fever Describe

Vision Testing Checkbox

Vision Testing

Vision Testing Age

Vision Testing Describe

Whooping Cough Checkbox

Whooping Cough

Whooping Cough Age

Whooping Cough Describe

Surgeries Checkbox

Surgeries

Surgeries Age

Surgeries Describe

Physical Injuries Checkbox

Physical Injuries

Physical Injuries Age

Physical Injuries Describe

None Checkbox

None

Section Divider

MEDICATIONS

If none, write "None"

Medication

Medication 1

Medication 2

Medication 3

Medication 4

What's it for?

What's it for 1

What's it for 2

What's it for 3

What's it for 4

Side Effects

Side Effects 1

Side Effects 2

Side Effects 3

Side Effects 4

ADAPTIVE EQUIPMENT

Adaptive Equipment Checkboxes

Adaptive Stroller
Supplemental Oxygen
Gait Trainer
Adaptive Toilet Chair
Wheelchair
Arm/Hand Braces
Apnea Monitor
Adaptive Bath Chair
Leg/Foot Braces
Heart Monitor
Stander
PECS
Tube Fed
Walker
Communication Device
Adaptive Chair (Describe)

Adaptive Chair description

Section Divider

SERVICES

Only one is required *

Services

Previously or Currently

Where and with whom?

Applied Behavioral Analysis Checkbox

Applied Behavioral Analysis

Applied Behavioral Analysis (Previously or Currently)

Applied Behavioral Analysis (Where and with whom)

Discrete Trials (DTT) Checkbox

Discrete Trials (DTT)

Discrete Trials (DTT) (Previously or Currently)

Discrete Trials (DTT) (Where and with whom)

Early intervention school Checkbox

Early intervention school

Early intervention school (Previously or Currently)

Early intervention school (Where and with whom)

Feeding therapy Checkbox

Feeding therapy

Feeding therapy (Previously or Currently)

Feeding therapy (Where and with whom)

Floortime Checkbox

Floortime

Floortime (Previously or Currently)

Floortime (Where and with whom)

Hippotherapy Checkbox

Hippotherapy

Hippotherapy (Previously or Currently)

Hippotherapy (Where and with whom)

Infant stimulation teacher Checkbox

Infant stimulation teacher

Infant stimulation teacher (Previously or Currently)

Infant stimulation teacher (Where and with whom)

Mobility specialist Checkbox

Mobility specialist

Mobility specialist (Previously or Currently)

Mobility specialist (Where and with whom)

Occupational therapy Checkbox

Occupational therapy

Occupational therapy (Previously or Currently)

Occupational therapy (Where and with whom)

Physical therapy Checkbox

Physical therapy

Physical therapy (Previously or Currently)

Physical therapy (Where and with whom)

Speech therapy Checkbox

Speech therapy

Speech therapy (Previously or Currently)

Speech therapy (Where and with whom)

Therapeutic horse riding Checkbox

Therapeutic horse riding

Therapeutic horse riding (Previously or Currently)

Therapeutic horse riding (Where and with whom)

Vision specialist Checkbox

Vision specialist

Vision specialist (Previously or Currently)

Vision specialist (Where and with whom)

Other Checkbox

Other

Other (Previously or Currently)

Other (Where and with whom)

None Checkbox

None

Next - Home and Community

HOME AND COMMUNITY

What aspect(s) of the day or daily routine is (are) the most difficult for your child? Why? *

What strategies do you find effective for calming your child when he/she becomes upset? *

Describe how your child transitions between new and familiar people? *

Describe how your child transitions between new and familiar environments? *

Describe your child’s leisure activities: *

List what your child usually does during these hours?

6 - 8 am

6-8am Activity 1

6-8am Activity 2

6-8am Activity 3

6-8am Activity 4

8 am - 12 noon

8am-12noon Activity 1

8am-12noon Activity 2

8am-12noon Activity 3

8am-12noon Activity 4

12 noon - 3 pm

12noon-3pm Activity 1

12noon-3pm Activity 2

12noon-3pm Activity 3

12noon-3pm Activity 4

3 - 6 pm

3-6pm Activity 1

3-6pm Activity 2

3-6pm Activity 3

3-6pm Activity 4

6 pm - Bedtime

6pm-Bedtime Activity 1

6pm-Bedtime Activity 2

6pm-Bedtime Activity 3

6pm-Bedtime Activity 4

Next - Sign & Submit

EDUCATIONAL INFORMATION

Teacher

Grade Level

1:1 instructional assistant Checkbox

1:1 instructional assistant

1:1 instructional assistant % of day:

School

Type of Classroom

Resource assistant Checkbox

Resource assistant

Resource assistant frequency:

Relationship with teacher:

Relationship with classmates:

Area of academic difficulty:

Area of most success or enjoyment:

Safety and independence in accessing the school environment:

Is there anything else you would like to tell us about your child?

SIGN & SUBMIT

Parent/Guardian/Legal Representative of Child *

Please sign below: *

Clear Signature

Date *