New Patient Intake Form New Patient Enter NA into any fields that do not apply. Child’s Legal Name: First Middle Last DOB Age Gender Phone Home Address: City State Zip Parent/Guardian 1 DOB Cell Parent/Guardian 2 DOB Cell Insurance Company ID CARD NUMBER Phone Medicaid Plan ID CARD NUMBER Who has legal custody of the child? Who lives in the home of the child? Name/Relationship to child/Age (if child): Emergency Contact Information: List who we may call in case of emergency AND who may pick up the child from appointments other than custodial parent or guardian. Name Phone Relationship Name Phone Relationship Area of Concerns: What is the primary concern for having your child evaluated? When did you start having concerns? What strategies have you already tried? What specific skills would you like your child to achieve in therapy? Prenatal/Birth History: List any complication during pregnancy: Any exposure to drugs or alcohol during pregnancy? YesNo Was your pregnancy full term? YesNo If NO, please give gestational age: Birth Weight: Method of Delivery: VaginalBreechCesarean Forceps or Suction used? YesNo Was oxygen or respiratory assistance required after birth? YesNo If YES, please explain: Did the child experience any complications with feeding? YesNo If YES, please explain: How was your child fed as an infant (Bottle, Breast Milk) and until what age? Please list any concerns regarding your child eating habits: History: Does your child currently receive therapy services at any other location? YesNo Where? List any medical diagnoses that your child has been given: List all your child’s medications: Developmental Milestones: (List age at time of reaching milestone without help) Rolling Spoke first word Sitting alone Puts several words together Crawling Toilet trained Walk alone Eats with utensils Dresses self Finger fed self Has your Child: Had his/her hearing checked? YesNo Date Results Had his/her vision checked? YesNo Date Results Had their immunizations? YesNo Are they up to date? YesNo Please list any allergies: Family history: Does anyone in your family have a history of the following: Communication difficulties? YesNo Describe difficulty Relationship to child Physical difficulties? YesNo Describe difficulty Relationship to child Learning disability? YesNo Describe difficulty Relationship to child Mental illness? YesNo Describe difficulty Relationship to child How may we contact you regarding information about your child? Home Phone / Voicemail Cell Phone / Voicemail Email How did you hear about us? Parent/Guardian Signature Print Name Date I, hereby authorize Connected-Kidz, LLC, to send me an appointment reminder via text or email and/or contact via phone call using the following information. Reminders may contain patient or clinic information such as, but not limited to, patient first name and clinic location. Patient/Guardian Contact Information (please print clearly & legibly): Email Cell Phone Parent/Guardian Name (print) Signature Date