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Full Name:

Age:

Gender:

Child’s Diagnosis:

Date of diagnosis:

Age at diagnosis:

Address:

City:

Country:

Father’s Name*:

Mother’s Name*:

Phone Number*:

Email*:

How you heard about us:

Is your child currently on any medications?

If yes, please list below. Medication/Supplements:

Has your child been diagnosed with any medical conditions (e.g., seizure disorders, cerebral palsy, diabetes, etc.):

Does your child have food or other types of allergies (peanuts, medication etc.):

Describe the skill areas that are a priority for your child (e.g. Language, socialization, problem behaviours):

Describe your short term and long term goals for your child:

Is your child enrolled in a school setting?

Does your child have a home program?

Please attach most recent provider reports including goals & objectives statements.

Please attach most recent ABLLS assessment or other similar assessments that have been completed.

Describe how your child indicates what he/she wants:

Describe your child’s ability to imitate vocal sounds, words, phrases:

Describe your child’s ability to follow directions and one-step instructions:

Is your child able to imitate simple motor movements such as clapping, and waving?

Does your child make eye contact with Mom Dad, Siblings, Familiar People, and Others? (check all that apply)

Describe your child’s response when addressed by others:

Describe your child’s gross motor skills in general (kick a ball, irregular walking/running, jump on one foot, etc.):

Can your child perform the following Activities of Daily Living (ADL) (check if Yes)

Describe your child’s self-help skills:

Describe in general your child’s behaviour at home and community:

Are there times when you have to modify family activities because of your child’s behaviour?

Please put a tick if your child engages in any of these:

Describe the items and activities that your child enjoys:

Please add any more information that will help us learn more about your child: