Initial Consultation Intake Form
Wellspring Learning, LLC
Initial Consultation Intake Form
CHILD'S INFORMATION
Today’s Date_________________
Name_________________________________________________
Age____ DOB___/__/___ Sex: ___ Grade in School___
School__________________________________________
Child’s First Language__________________ Primary Language at Home_______________
PARENT/ CAREGIVER INFORMATION
Parents/ Caregiver and Relationship to Child:__________________________________
_____________________________________________________________________________
Contact information:
1st Person______________________________ E-Mail _____________________________
Address____________________________City_______________Zip Code_____________
Phone:
Home_____________Work_____________Cell____________Fax_____________________
2nd Person _____________________________ E- Mail_____________________________
Address____________________________City_______________Zip Code______________
Phone:
Home______________ Work______________ Cell_____________ Fax_______________
INTEREST IN THE PROGRAM / REFERRAL INFORMATION
Please tell us about areas of concerns about for your child and the main reason for coming here today.
Academically___________________________________________________________
Developmentally________________________________________________________
Socially ________________________________________________________________
Referred by___________________Phone___________________Address___________
__________________________________________________________________________
May we send a thank you note to your referral source? ____Yes ____No
(Wellspring Learning, LLC has my permission to send a thank you note to my referral source indicating my child has been seen for the initial consultation. No other information will be released without written consent).
Parent or Guardian____________________________
Date____________________
FAMILY HISTORY
Parents’ Status (circle one) married/ single/ separated/ divorced/ deceased
Do both parents live at home? Y/N___
Is there a stepmother/ stepfather? (Circle one if applicable)
Parents’ Profession:
Mother___________________________________________________________________
Father____________________________________________________________________
Siblings:
Name(S) _________________________________________________________________
Age(s) ___________________________________________________________________
N=Natural
A=Adopted
S=Step Y/N
Other Caregivers :( daycare providers, regular babysitters, nanny, family, etc.).
_________________________________________________________________________
What history is there in the family regarding developmental, learning, and communication disorders?
These may include: Autism, Attention Deficit Disorder, Dyslexia, etc.
_______________________________________________________________________________
CHILD’S DEVELOPMENTAL/ HEALTH HISTORY
(If adopted please complete as much as possible including the “Adoption” section.)
Prenatal:
Was the pregnancy planed? _______Was hormone therapy used for conception? ______
Did the mother experience any health difficulties during the pregnancy?
_______________________________________________________________________________
Was there any other medical diagnostic and treatment during the pregnancy? (If yes, please
explain)._________________________________________________________________________
Was the mother exposed to medication, smoking, alcohol, or to persistent loud sounds (e.g., plane engines, equipment)? (If yes please comment). ________________________________________________________________________________
Did the mother live and work in a different country during the pregnancy? Y/N Language(s) spoken at that time? _____________________________
Labor and Delivery:
Labor length ____________ APGAR_______________ Birth Weight_______________
Was the delivery at full term? Y/N _______
Was the delivery induced? Y/N _______
Was the delivery a Cesarian Section? Y/N _____
Where there any complications during the delivery process? ________________________
(e.g. Clavicle Fracture, Breech Delivery, etc.)
Adoption:
Child’s age when adopted_______ Country of adoption_________________________________
Please comment on the adoption process and if you have any information about birth
parents.______________________________________________________________________
How do you feel the child has adjusted to his/her new home? _____________________________
_________________________________________________________________________________________
Is the child aware of adoption? ___________________________________________________________
Infancy:
Did the child have a good sleep/awake rhythm? Was the baby active or quiet? Was the baby fussy or happy? Was the baby colicky for a long time? (Please describe) __________________________________________________________________________________
What helped the most to calm your baby when he/she was fussy or cried?
___________________________________________________________________________________________
Was the baby breast-fed? Y/N _____ until what age? ________ was it easy or difficult for the baby to
Breast-feed? ______________________________
Did the child prefer to spend most of the time on: the belly, on the back? (Please circle)
Did the child have any long term medication or hospitalization/ surgeries during infancy? Was there any medical condition diagnosed at that time? (Please describe) _____________________________________________________________________________________
Was the baby separated from the mother for an extended period of time? ___________________________________
Childhood Developmental Milestones (sensory-motor, Speech, and Vision)
Motor:
Did your child:
Role sideways? Y/N__ At what age (mos.)?____ Sat alone? Y/N___ at what age (mos.)?____
Creep (Stomach on floor)? Y/N ____At what age (mos.)?___
Crawl (Stomach off floor)? Y/N____ At what age? ____ Describe crawling style and quality.
____________________________________________________________________________
Walk without holding? Y/N____ At what age? _____ (mos.)
For how long did the child crawl before walking? ___ (mos.)
After beginning walking did the child fall: often, seldom, or not at all? (Please circle)
Speech:
When did the child first:
Babble? _____ (mos.) Said first words? ______ (mos.).
Use 2-3 word phrases_____ (mos.).
Did other people understand the child’s speech? Y/N
Was it necessary to have a speech and language evaluation? Y/N __ at what age? ___ (mos.)
Did the child have his/her hearing tested? Y/N_____ At what age? _____ (mos.)
Test results from the audiologist:_____________________________________________
Did the child have repetitive ear infection? Y/N ___ how often? (During the first 5 years of life)____
Vision:
Has the child had an eye exam? Y/N_______ Date of child’s last exam and findings: ______________________________________________________________________________
Has your child’s ability to do any activity been restricted because of vision problems? Y/N____
Please describe _________________________________________________________________
Has the child ever worn glasses? Y/N______ If yes, for distance only Y/N? For near only Y/N?
Does the child wear contact lenses? Y/N
Does the child wear glasses now? Y/N________ Does the child wear them full time? Y/N
Any problems? ________________________________________________________________
Health:
How would you describe the child’s health during the child’s first two years of life? ____________________________________________________________________________________
____________________________________________________________________________________
How would you describe the child’s health since age two?
_____________________________________________________________________________________
_____________________________________________________________________________________
When was the child’s most recent check-up? _____________
Physician:_______________________________________________
Is your child in good general health at the present time? ________________________________
_______________________________________________________________________________________
Are you aware of any ear, sinus, and respiratory tract infections at the present time? Y/N_____
Is the child currently taking any medication? Y/N_____
Specify medication, dosage, and for what condition.
_____________________________________________________________________________________
_____________________________________________________________________________________
Physician: __________________________ Phone Number _________________________________
Has medication been prescribed in the past to help behavior, attention and mood? Y/N____
If yes, for what condition? ____________________________________________________________________________________
Does the medication help? ___________________________________________________________________________________
Check any conditions that apply to your child or that run in your family:
Allergies _____
Autism/PDD/Asperger’s _____
Dermatological Problems _____
Diabetes _____
Drug Sensitivity _____
Ear, Sinus Infections _____
Encopresis _____
Enuresis (bedwetting) _____
Environmental Sensitivities _____
Genetic Syndromes _____
G I Tract Problems _____
Head Aches _____
Heart Problems _____
Injuries/ Head Trauma _____
Sensory Disorders _____
Respiratory Disease _____
Seizure Disorder _____
Sleeping Disorder _____
Surgical Interventions _____
Thyroid Problems _____
Previous Evaluations and Treatments:
Has your child been evaluated and treated by a physical or occupational therapist? Y/N__
Findings: _______________________________________________________________
Dates of treatment: _____________________________________________________
Has your child been evaluated and treated by a speech and language pathologist or audiologist for speech and auditory problems? Y/N _______
Findings: ________________________________________________________________________
Dates of treatment:_______________________________________________________________
Has your child been evaluated and treated by a psychologist or learning consultant? Y/N
Findings: ________________________________________________________________
Dates of treatment: ______________________________________________________
Does your child have an IEP? _____________________________________________
Special School Services/Classes? __________________________________________
__________________________________________________________________________
Has your child been evaluated and treated by an ENT? Y/N
Findings and treatment: _____________________________________________________
Has your child been evaluated and treated by a developmental pediatrician, neurologist or psychiatrist? Y/N_______
If Yes please specify:_________________________________________________________________
Findings and treatment: ______________________________________________________________
Has your child been evaluated and treated by an osteopathic naturopathic physician? Y/N_______
If yes please specify:_______________________________________________________________
Findings and treatment:____________________________________________________________
Sensory-Motor Development:
Laterality development:
Hand Dominance established? Y/N____ If yes: R____ L______
Foot Dominance established? Y/N_____ If yes: R____ L______
Muscle Tone Regulation:
Does the child:
Have a very sloppy/ poor posture? Y/N
Have a too loose or too strong grasp of a pencil which is less mature than peers? Y/N___
Drool when at rest? Y/N___ Drools when manipulating objects or when in action? Y/N__
Have any neuro muscular pathology :( e.g. CP, spasticity, myopathy)? Y/N ___
Coordination, Body Scheme Awareness:
Does the child:
Appear clumsy, bumps into others? Y/N____
Have difficulties playing on playground structures? Y/N____
Have difficulties manipulating with small objects? Y/N____
Have difficulties dressing himself/herself and fastening clothes? Y/N ____
Have difficulties eating independently while using silverware? Y/N____
Have difficulties riding a tricycle/bicycle? Y/N____
Tactile Perception:
Does the child:
Dislike to being touched/cuddled? Y/N_____
Object to the feel of certain clothes’ texture? Y/N____
Object to having fingernails clipped, and haircut, teeth brushed? Y/N_____
Dislike to having face/hair washed or head under the water? Y/N____
Prefer to avoid other children’s presence? Y/N______
Vestibular Perception:
Does your child:
Feel the need to swing or spin/ self-spin very often? Y/N___
Appear very hesitant when walking stairs and experiencing height? Y/N ____
Appear very cautious when in a larger and very active group of children? Y/N____
Choose to play the less active role in different sport activities? Y/N___
For evaluations, may I contact your child’s teacher(s) at school for further information as it relates to this assessment? Y/N
Contact Person (please include phone number): ____________________________________________
Please check which areas below are most important to you to change:
Attention ____
Behavior_____
Sleeping patterns____
Emotional ____
Development_____
Flexibility & transitioning ____
Focusing____
Following directions ___
Learning/Academics____
Language____
Memory____
Motor skills (describe) ____________________________________________
Organizational skills____
Reading & spelling___
Sensitivities (auditory, vestibular, visual, tactile) ___
Speech (describe) _________________________________________________
Social Skills___
Self-Esteem____
Sleeping Patterns___
Please check from the list below, which areas you are ready to improve?
Attention
Academic Learning
Behavior
Critical thinking
Emotional development
Listening
Math understanding
Memory
Motor skills
Organizational skills
Reading & Spelling
Social Skills
Speaking
Questionnaire completed by:______________________________ Date: _____/___/_____
Please tell us what your desired goals are for the treatment.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please include time-frames and specific physical/learning/emotional improvements:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parent signature: ___________________________________________
Date: ____/_____/_____
Initial Consultation Intake Form
CHILD'S INFORMATION
Today’s Date_________________
Name_________________________________________________
Age____ DOB___/__/___ Sex: ___ Grade in School___
School__________________________________________
Child’s First Language__________________ Primary Language at Home_______________
PARENT/ CAREGIVER INFORMATION
Parents/ Caregiver and Relationship to Child:__________________________________
_____________________________________________________________________________
Contact information:
1st Person______________________________ E-Mail _____________________________
Address____________________________City_______________Zip Code_____________
Phone:
Home_____________Work_____________Cell____________Fax_____________________
2nd Person _____________________________ E- Mail_____________________________
Address____________________________City_______________Zip Code______________
Phone:
Home______________ Work______________ Cell_____________ Fax_______________
INTEREST IN THE PROGRAM / REFERRAL INFORMATION
Please tell us about areas of concerns about for your child and the main reason for coming here today.
Academically___________________________________________________________
Developmentally________________________________________________________
Socially ________________________________________________________________
Referred by___________________Phone___________________Address___________
__________________________________________________________________________
May we send a thank you note to your referral source? ____Yes ____No
(Wellspring Learning, LLC has my permission to send a thank you note to my referral source indicating my child has been seen for the initial consultation. No other information will be released without written consent).
Parent or Guardian____________________________
Date____________________
FAMILY HISTORY
Parents’ Status (circle one) married/ single/ separated/ divorced/ deceased
Do both parents live at home? Y/N___
Is there a stepmother/ stepfather? (Circle one if applicable)
Parents’ Profession:
Mother___________________________________________________________________
Father____________________________________________________________________
Siblings:
Name(S) _________________________________________________________________
Age(s) ___________________________________________________________________
N=Natural
A=Adopted
S=Step Y/N
Other Caregivers :( daycare providers, regular babysitters, nanny, family, etc.).
_________________________________________________________________________
What history is there in the family regarding developmental, learning, and communication disorders?
These may include: Autism, Attention Deficit Disorder, Dyslexia, etc.
_______________________________________________________________________________
CHILD’S DEVELOPMENTAL/ HEALTH HISTORY
(If adopted please complete as much as possible including the “Adoption” section.)
Prenatal:
Was the pregnancy planed? _______Was hormone therapy used for conception? ______
Did the mother experience any health difficulties during the pregnancy?
_______________________________________________________________________________
Was there any other medical diagnostic and treatment during the pregnancy? (If yes, please
explain)._________________________________________________________________________
Was the mother exposed to medication, smoking, alcohol, or to persistent loud sounds (e.g., plane engines, equipment)? (If yes please comment). ________________________________________________________________________________
Did the mother live and work in a different country during the pregnancy? Y/N Language(s) spoken at that time? _____________________________
Labor and Delivery:
Labor length ____________ APGAR_______________ Birth Weight_______________
Was the delivery at full term? Y/N _______
Was the delivery induced? Y/N _______
Was the delivery a Cesarian Section? Y/N _____
Where there any complications during the delivery process? ________________________
(e.g. Clavicle Fracture, Breech Delivery, etc.)
Adoption:
Child’s age when adopted_______ Country of adoption_________________________________
Please comment on the adoption process and if you have any information about birth
parents.______________________________________________________________________
How do you feel the child has adjusted to his/her new home? _____________________________
_________________________________________________________________________________________
Is the child aware of adoption? ___________________________________________________________
Infancy:
Did the child have a good sleep/awake rhythm? Was the baby active or quiet? Was the baby fussy or happy? Was the baby colicky for a long time? (Please describe) __________________________________________________________________________________
What helped the most to calm your baby when he/she was fussy or cried?
___________________________________________________________________________________________
Was the baby breast-fed? Y/N _____ until what age? ________ was it easy or difficult for the baby to
Breast-feed? ______________________________
Did the child prefer to spend most of the time on: the belly, on the back? (Please circle)
Did the child have any long term medication or hospitalization/ surgeries during infancy? Was there any medical condition diagnosed at that time? (Please describe) _____________________________________________________________________________________
Was the baby separated from the mother for an extended period of time? ___________________________________
Childhood Developmental Milestones (sensory-motor, Speech, and Vision)
Motor:
Did your child:
Role sideways? Y/N__ At what age (mos.)?____ Sat alone? Y/N___ at what age (mos.)?____
Creep (Stomach on floor)? Y/N ____At what age (mos.)?___
Crawl (Stomach off floor)? Y/N____ At what age? ____ Describe crawling style and quality.
____________________________________________________________________________
Walk without holding? Y/N____ At what age? _____ (mos.)
For how long did the child crawl before walking? ___ (mos.)
After beginning walking did the child fall: often, seldom, or not at all? (Please circle)
Speech:
When did the child first:
Babble? _____ (mos.) Said first words? ______ (mos.).
Use 2-3 word phrases_____ (mos.).
Did other people understand the child’s speech? Y/N
Was it necessary to have a speech and language evaluation? Y/N __ at what age? ___ (mos.)
Did the child have his/her hearing tested? Y/N_____ At what age? _____ (mos.)
Test results from the audiologist:_____________________________________________
Did the child have repetitive ear infection? Y/N ___ how often? (During the first 5 years of life)____
Vision:
Has the child had an eye exam? Y/N_______ Date of child’s last exam and findings: ______________________________________________________________________________
Has your child’s ability to do any activity been restricted because of vision problems? Y/N____
Please describe _________________________________________________________________
Has the child ever worn glasses? Y/N______ If yes, for distance only Y/N? For near only Y/N?
Does the child wear contact lenses? Y/N
Does the child wear glasses now? Y/N________ Does the child wear them full time? Y/N
Any problems? ________________________________________________________________
Health:
How would you describe the child’s health during the child’s first two years of life? ____________________________________________________________________________________
____________________________________________________________________________________
How would you describe the child’s health since age two?
_____________________________________________________________________________________
_____________________________________________________________________________________
When was the child’s most recent check-up? _____________
Physician:_______________________________________________
Is your child in good general health at the present time? ________________________________
_______________________________________________________________________________________
Are you aware of any ear, sinus, and respiratory tract infections at the present time? Y/N_____
Is the child currently taking any medication? Y/N_____
Specify medication, dosage, and for what condition.
_____________________________________________________________________________________
_____________________________________________________________________________________
Physician: __________________________ Phone Number _________________________________
Has medication been prescribed in the past to help behavior, attention and mood? Y/N____
If yes, for what condition? ____________________________________________________________________________________
Does the medication help? ___________________________________________________________________________________
Check any conditions that apply to your child or that run in your family:
Allergies _____
Autism/PDD/Asperger’s _____
Dermatological Problems _____
Diabetes _____
Drug Sensitivity _____
Ear, Sinus Infections _____
Encopresis _____
Enuresis (bedwetting) _____
Environmental Sensitivities _____
Genetic Syndromes _____
G I Tract Problems _____
Head Aches _____
Heart Problems _____
Injuries/ Head Trauma _____
Sensory Disorders _____
Respiratory Disease _____
Seizure Disorder _____
Sleeping Disorder _____
Surgical Interventions _____
Thyroid Problems _____
Previous Evaluations and Treatments:
Has your child been evaluated and treated by a physical or occupational therapist? Y/N__
Findings: _______________________________________________________________
Dates of treatment: _____________________________________________________
Has your child been evaluated and treated by a speech and language pathologist or audiologist for speech and auditory problems? Y/N _______
Findings: ________________________________________________________________________
Dates of treatment:_______________________________________________________________
Has your child been evaluated and treated by a psychologist or learning consultant? Y/N
Findings: ________________________________________________________________
Dates of treatment: ______________________________________________________
Does your child have an IEP? _____________________________________________
Special School Services/Classes? __________________________________________
__________________________________________________________________________
Has your child been evaluated and treated by an ENT? Y/N
Findings and treatment: _____________________________________________________
Has your child been evaluated and treated by a developmental pediatrician, neurologist or psychiatrist? Y/N_______
If Yes please specify:_________________________________________________________________
Findings and treatment: ______________________________________________________________
Has your child been evaluated and treated by an osteopathic naturopathic physician? Y/N_______
If yes please specify:_______________________________________________________________
Findings and treatment:____________________________________________________________
Sensory-Motor Development:
Laterality development:
Hand Dominance established? Y/N____ If yes: R____ L______
Foot Dominance established? Y/N_____ If yes: R____ L______
Muscle Tone Regulation:
Does the child:
Have a very sloppy/ poor posture? Y/N
Have a too loose or too strong grasp of a pencil which is less mature than peers? Y/N___
Drool when at rest? Y/N___ Drools when manipulating objects or when in action? Y/N__
Have any neuro muscular pathology :( e.g. CP, spasticity, myopathy)? Y/N ___
Coordination, Body Scheme Awareness:
Does the child:
Appear clumsy, bumps into others? Y/N____
Have difficulties playing on playground structures? Y/N____
Have difficulties manipulating with small objects? Y/N____
Have difficulties dressing himself/herself and fastening clothes? Y/N ____
Have difficulties eating independently while using silverware? Y/N____
Have difficulties riding a tricycle/bicycle? Y/N____
Tactile Perception:
Does the child:
Dislike to being touched/cuddled? Y/N_____
Object to the feel of certain clothes’ texture? Y/N____
Object to having fingernails clipped, and haircut, teeth brushed? Y/N_____
Dislike to having face/hair washed or head under the water? Y/N____
Prefer to avoid other children’s presence? Y/N______
Vestibular Perception:
Does your child:
Feel the need to swing or spin/ self-spin very often? Y/N___
Appear very hesitant when walking stairs and experiencing height? Y/N ____
Appear very cautious when in a larger and very active group of children? Y/N____
Choose to play the less active role in different sport activities? Y/N___
For evaluations, may I contact your child’s teacher(s) at school for further information as it relates to this assessment? Y/N
Contact Person (please include phone number): ____________________________________________
Please check which areas below are most important to you to change:
Attention ____
Behavior_____
Sleeping patterns____
Emotional ____
Development_____
Flexibility & transitioning ____
Focusing____
Following directions ___
Learning/Academics____
Language____
Memory____
Motor skills (describe) ____________________________________________
Organizational skills____
Reading & spelling___
Sensitivities (auditory, vestibular, visual, tactile) ___
Speech (describe) _________________________________________________
Social Skills___
Self-Esteem____
Sleeping Patterns___
Please check from the list below, which areas you are ready to improve?
Attention
Academic Learning
Behavior
Critical thinking
Emotional development
Listening
Math understanding
Memory
Motor skills
Organizational skills
Reading & Spelling
Social Skills
Speaking
Questionnaire completed by:______________________________ Date: _____/___/_____
Please tell us what your desired goals are for the treatment.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please include time-frames and specific physical/learning/emotional improvements:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parent signature: ___________________________________________
Date: ____/_____/_____