Thank you for completing the form. I look forward to seeing you soon.1 0% https://mindandbodydoctor.com/wp-content/plugins/nex-forms-litefalsemessagehttps://mindandbodydoctor.com/wp-admin/admin-ajax.phphttps://mindandbodydoctor.com/child-intakeyes *Child’s Name*Date of Appointment*Date of Birth*Age*Gender:— Select —MaleFemaleOther*School name*Grade*Primary Spoken LanguageSecondary Language*Person Completing Form*Relationship to Child*Marital Status*Home Address*Best Contact NumberOk to leave a message? –Select– –Select– Yes Yes No No *Emergency Contact Name and NumberWho may I thank for referring you to my office? For testing: In order to assure validity of testing, the same tests cannot be administered within a twelve month period of time. I hereby attest that my child has not been administered or exposed to the same tests that will be administered by Dr. Cherwony during the past twelve months. I further understand that no less than 72 hours advanced notice must be provided in the event that appointment needs to be canceled. Failure to provide such notification will result in an assessment fee of $250 and any rescheduled appointments will require full payment in advance. *Parent/Legal Guardian SignatureParent Information*Parent/Legal Guardian Name*Age*Occupation*Highest degree or level of education *Best Contact NumberParent 2 NameAgeOccupationHighest degree or level of education Best Contact NumberIs child living with both parents? –Select– –Select– Yes Yes No No If parents are living apart (or separated or divorced) is other parent aware that you are seeking psychological services for your child? –Select– –Select– Yes Yes No No If child is not living with both biological parents, please describe living and visitation arrangementsSiblings living at home | Sex | Age | SchoolOther persons living in the home / RelationOther siblings living outside the home | Sex | AgeDEVELOPMENTAL AND HEALTH INFORMATIONPediatrician’s nameOffice numberHeightWeightMedication (and dosage) taken at this timeDate of last medical checkup?What is your child’s present health? –Select– –Select– Excellent Excellent Good Good Fair Fair Please explainDoes your child have allergies? –Select– –Select– Yes Yes No No List:Is there a history of ear infections? –Select– –Select– Yes Yes No No If yes, list frequencyHas your child ever had head injuries, seizures, hospitalizations, or surgery? –Select– –Select– Yes Yes No No If yes, please explainApproximate weight at birthMonths CarriedType of delivery –Select– –Select– Vaginal Vaginal C-Section C-Section Mother’s age at deliveryHealth during pregnancyDescribe any complications during pregnancy or birthPlease indicate the time frame your child reached the following Developmental Milestones: Sitting Alone –Select– –Select– Early Early Typical Typical Late Late Unknown Unknown Crawling –Select– –Select– Early Early Typical Typical Late Late Unknown Unknown Standing Alone –Select– –Select– Early Early Typical Typical Late Late Unknown Unknown Walking Alone –Select– –Select– Early Early Typical Typical Late Late Unknown Unknown Spoke First Words –Select– –Select– Early Early Typical Typical Late Late Unknown Unknown Spoke Short Sentences –Select– –Select– Early Early Typical Typical Late Late Unknown Unknown What age was your child able to stay dry during daytimeand nighttimePlease mark any areas that constitute a problem for your child: –Select– –Select– Eating Eating Sleeping Sleeping Nightmares Nightmares Thumb sucking Thumb sucking Nail biting Nail biting Getting along with friends Getting along with friends Self-help skills (dressing, bathing, etc.) Self-help skills (dressing, bathing, etc.) Unusual fears (describe)OtherPlease check all that apply –Select– –Select– Visual difficulties Visual difficulties Supposed to wear glasses Supposed to wear glasses Hearing difficulties Hearing difficulties Supposed to wear a hearing aid Supposed to wear a hearing aid Has Pressure equalization tubes Has Pressure equalization tubes Fine motor difficulties Fine motor difficulties Gross motor difficulties Gross motor difficulties Sensitivity to smell Sensitivity to smell Sensitivity to light Sensitivity to light Sensitivity to touch Sensitivity to touch Sensitivity to loud sounds Sensitivity to loud sounds Sensitivity to other Sensitivity to other Has your child received any of the following services? Speech Therapy? Occupational Therapy? Physical Therapy? –Select– –Select– Yes Yes No No If so, please explainSCHOOL AND EDUCATIONAL HISTORYAge began daycare, nursery, or preschoolAge started KindergartenList schools your child has attended | Name | City | Years/Grade(s) Name of zoned public schoolIs your child in special classes? –Select– –Select– Yes Yes No No If yes, what kind?Has your child ever repeated a grade/retained? –Select– –Select– Yes Yes No No Which grade?Is there any family member who presently or in the past have (had) learning and/or attention difficulties, or was in special classes? –Select– –Select– Yes Yes No No If yes, who and what kind/type?For children in K-12, what kind of grades does your child typically earn? Describe any problems your child might be having in school and when you first noticed these problems?In what school situations or subjects does your child perform best? In what school situations or subjects does your child perform worst?SOCIAL AND EMOTIONAL INFORMATIONList your child’s major interests and hobbiesIs your child involved in extracurricular activities? –Select– –Select– Yes Yes No No If yes, what kind?When interacting with same-aged peers, your child can be described as: –Select– –Select– Friendly Friendly Thoughtful Thoughtful Engaged Engaged Leader Leader Follower Follower Assertive Assertive Shy Shy Aggressive Aggressive Withdrawn Withdrawn Bossy Bossy Disinterested Disinterested Anxious Anxious OtherDo you have any concerns about your child’s mood?How many friends does your child have? #male #femaleDo any family members have a history of mental health concerns? –Select– –Select– Yes Yes No No If yes, who and what kindPlease put any other comments that will help me understand your child betterSubmit
