Wellspring Tomatis Listening Center
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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: ____/_____/_____ 


We Would Love to Have You Visit Soon!


Hours

M-F: 9am - 6pm

Telephone

908 922-3309

Email

contact@wellspringlearningcenter.com