PEDIATRIC THERAPIES at COOL SPRINGS
Phone: 615-377-1623
1880B General George Patton Drive
Suite 202
Franklin, TN 37067
Fax: 615-377-1625
NEW CLIENT FORM
Today’s Date: _____________________
Child’s Name: ________________________________________ Birth Date: _______________________
Person Completing Form: ______________________________ Relationship to Child: _______________
Pediatrician: _____________________________ Referring Physician: ____________________________
What prompted this evaluation? Please list specific concerns (i.e. motor, sensory, behavior, language):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are there other areas of development that are of concern to you? ______________________________
_____________________________________________________________________________________
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Current diagnoses: _____________________________________________________________________
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Family History:
Lives with both parents: Yes _____ No _____ If no, describe: _______________
_____________________________________________________________________________________
Siblings (names, ages, any history of delays): ________________________________________________
_____________________________________________________________________________________
Birth History:
Is this child: Biological child _____ Adopted child _____
Please indicate: Length of pregnancy: __________ Birth weight: __________
Notable circumstances during pregnancy, labor, delivery, and/or following birth: ___________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Medical History:
Please circle any of the following illnesses that are common conditions in your child or which your child
has acquired. List approximate ages in the space provided.
Allergies _______
Asthma _______
Chicken Pox _______
Colds _______
Croup _______
Ear Infections _______
Headaches _______
High Fever _______
Measles _______
Pneumonia _______
Seizures _______
Sinusitis _______
Tonsillitis/Adenoids _______
Other __________________________________________________
Pediatric Therapies 3-14
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New Client Form
Has your child had a vision test/screening? Yes No Date: _______________
Results: ______________________________________________________________________________
Has your child had a hearing test/screening? Yes No Date: _______________
Results: ______________________________________________________________________________
Significant illnesses: ____________________________________________________________________
_____________________________________________________________________________________
Specialists/Physicians seen (include dates, names, specialty): ___________________________________
_____________________________________________________________________________________
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Special Tests (X-rays, MRIs, etc.) including dates: _____________________________________________
_____________________________________________________________________________________
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Hospitalizations/Surgeries including dates: __________________________________________________
_____________________________________________________________________________________
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Precautions: __________________________________________________________________________
_____________________________________________________________________________________
Medications your child is taking and for what condition: _______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Developmental History:
Please indicate at what age your child achieved the following developmental milestones:
Sitting: ________
Crawling: ________
Standing: ________
Walking: ________
Babbling: ________
Single words: ________
Combining words: ________
Toilet training: ________
Describe overall coordination: ____________________________________________________________
_____________________________________________________________________________________
Are there currently or have there been any feeding problems (i.e. sucking, swallowing, drooling,
chewing, extreme picky eating, etc.)? Please explain: _________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe your child’s current vocabulary: ___________________________________________________
_____________________________________________________________________________________
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Pediatric Therapies 3-14
New Client Form
How many words is he/she using?
1000’s_____ 100s_____ 50–100_____
25–50_____ 10-25_____ 10 or less_____ none_____
If non-verbal, how does he/she communicate? ______________________________________________
_____________________________________________________________________________________
Describe social language abilities: _________________________________________________________
_____________________________________________________________________________________
Educational History: School: _________________________________________ Grade: _____________
Please indicate your child’s school schedule (i.e. days, times, etc.): ______________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List your child’s teacher or other appropriate contact person and phone number: __________________
_____________________________________________________________________________________
Describe your child’s school performance: __________________________________________________
_____________________________________________________________________________________
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What if any special services does your child receive at school? __________________________________
_____________________________________________________________________________________
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Previous Assessments and Therapies:
Please list any other evaluations, including dates that your child has undergone or has pending (i.e. OT,
PT, Speech and Language, Psychoeducational, etc.). List contact names and phone numbers.
OT: __________________________________________________________________________________
PT: __________________________________________________________________________________
SLT: _________________________________________________________________________________
Other: _______________________________________________________________________________
_____________________________________________________________________________________
Please list any developmental therapies or interventions your child has participated in or is currently
participating in (i.e. OT, PT, SLT, Music Therapy, counseling, etc.). Include dates: ___________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Social Information:
Personality characteristics: ______________________________________________________________
_____________________________________________________________________________________
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Pediatric Therapies 3-14
New Client Form
Interests/hobbies: _____________________________________________________________________
_____________________________________________________________________________________
Describe peer relations: _________________________________________________________________
_____________________________________________________________________________________
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Describe your child’s most concerning/challenging behaviors: __________________________________
_____________________________________________________________________________________
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Additional Comments:
My child’s strengths are: ________________________________________________________________
_____________________________________________________________________________________
My child’s greatest challenges are: ________________________________________________________
_____________________________________________________________________________________
My child’s fears are: ____________________________________________________________________
_____________________________________________________________________________________
What works to motivate or reward your child? ______________________________________________
_____________________________________________________________________________________
What are the most important skills you hope for your child to improve upon or develop? ____________
_____________________________________________________________________________________
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What other information would you like for us to know about your child? _________________________
_____________________________________________________________________________________
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Signature
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Date
Pediatric Therapies 3-14