New Client Packet

Please complete the following forms prior to your evaluation or first session at The Kids' Communication Center.

Page 1

CLIENT INFORMATION

Child's First Name

Child's Middle Name

Child's Last Name

Child's Date of Birth

Sex

Resonsible Party

Today's Date

Relationship to Child

Cell Phone

Work Phone

Home Phone

Address

E-mail

Name of Caregiver/Nanny

Phone & E-mail of Caregiver/Nanny

Does your child have any siblings?

If yes, what are their ages?

Pediatrician

Pediatrician's Address

Has your child ever been given a medial diagnosis?

If yes, what diagnosis?

What was the treatment?

Were there any complictions (e.g., maternal health problems, bed-rest, medications) with the pregnancy?

Explain.

How long was the mother on bed-rest?

Was the child born premature?

Please provide details as to difficulties and treatment.

Were there any complications during labor and/or delivery (e.g., forceps, vacuum extraction)? Explain.

Apgar scores:

Child's birth weight:

Was your child admitted to the NICU?

If so, explain (include length of stay).

Was your child nursed?

If so, until what age?

Was there anything remarkable about your child's early feeding history?

Has your child ever suffered from ear infections?

If yes, how many?

Which ears?

At what age(s)?

Were PE tubes inserted?

If yes, at what age?

Does your child have fluid in his/her ears?

If yes, for how long?

Has your child's hearing been tested?

Where?

When?

What were the results?

Is your child sensitive to certain sounds/pitches (e.g., vacuum cleaners, blenders)?

Does your child cover his/her ears when he/she hears certain sounds? (specify)

Clicking Submit will take you to page 2.