CHILD INTAKE FORM – PranaMind

Pranamind Child Intake Form

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Child Intake Form

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Child’s Name

First

Last

Birthdate

Age

Address

Zip Code

Phone

Cellphone

Work Phone

School

Grade

Primary Language

Secondary language spoken at home

Who referred you to our program?

How did you hear about us?

Medical Insurance

Account#

What are your main concerns about your child? Please describe in detail.

Aggravating Factors

Relieving Factors

Does your child have regularly scheduled meals?

Does your child drink caffeinated beverages?

If yes, how many per day?

Does your child have a standard bed time?

How many hours a night does your child sleep?

Has your child ever been arrested/detained?

If yes, when and why?

Has your child ever been sent to a correctional facility?

Is your child currently in a corrections program?

Has your child been suspended or expelled from school?

Exercise Type

Exercise Frequency

Allergies

What medications are you currently using?

Previous diagnoses/mental health treatment

Previously treated by

Previous medications

Dates treated:

Previous medical conditions:

Does child have a history of Ear infections

DESCRIBE (What/When?) Treatment (Ear infections)

Does child have a history of Seizures

DESCRIBE (What/When?) Treatment (Seizures)

Does child have a history of Surgeries

DESCRIBE (What/When?) Treatment (Surgeries)

Does child have a history of Serious Illness

DESCRIBE (What/When?) Treatment (Serious Illness)

Does child have a history of Head Trauma

DESCRIBE (What/When?) Treatment (Head Trauma)

Does child have a history of Heart Problems

DESCRIBE (What/When?) Treatment (Heart Problems)

Does child have a history of Special Syndrome

DESCRIBE (What/When?) Treatment (Special Syndrome)

Does child have a history of Other

DESCRIBE (What/When?) Treatment (Other)

Ha your child had a Vision Test

Has your child had a Vision Test (copy)

Vision Test DATE & by WHOM

Has your child had a Hearing Test (copy)

Hearing Test DATE & by WHOM

Does your child wear glasses

Please tell us why they were prescribed (vision)

Does your child use hearing aids or other listening devices?

Please tell us why they were prescribed (hearing)

Do you have concerns about your child’s social/emotional development or ability to get along with others?

Please describe your concerns

Siblings and their ages:

Dropdown

Parent's Name

First

Last

Education Level

Age

Any learning, developmental, or health problems? If yes, please describe

Name of Sibling 1

Age (1)

Any learning, developmental, or health problems? (1)

Name of Sibling 2

Age (2)

Any learning, developmental, or health problems? (2)

Name of Sibling 3

Age (3)

Any learning, developmental, or health problems? (3)

Are both parents living in the home?

Did the child's parents divorce?

If yes, how old was child when they divorced?

Selected Value: 5

Did the child's parents remarry?

If yes, how old was child when they remarried? (copy)

Selected Value: 5

Who raised the child?

Where did the child grow up?

Is the child adopted?

If yes, how old was child when they were adopted?

Selected Value: 5

Is there a family history of Speech delays?

Relation to Child (Speech delays)

Is there a family history of Development delays?

Relation to Child (Development delays)

Is there a family history of Autism?

Relation to Chid (Autism)

Is there a family history of Learning disabilities?

Relation to Chid (Learning disabilities)

Is there a family history of Other

Relation to Chid (Other)

Have there been any home/family experiences or changes that may have had an impact on your child (divorice, death, frequent residence changes, prolonged illnesses)?

Have you (the parent/guardian) ever been incarcerated? If yes, when and for how long

Have you (the parent/guardian) ever been homeless? If yes, when and for how long

Have you been on or are currently receiving public assistance?

Are you a member of a religion/spiritual group?

Is your child a member of a religious/spiritual group?

What activities does your child participate in surrounding the religion/spiritual group?

Illness during pregnancy

Describe Illness during pregnancy

Accidents during pregnancy

Describe Accidents during pregnancy

Exposure to toxins, x-ray

Describe Exposure to toxins, x-ray

Cigarettes, alcohol, drugs during pregnancy

Describe Cigarettes, alcohol, during pregnancy

Other complications during pregnancy

Describe Other complications during pregnancy

Medications during pregnancy (copy)

Describe Medications during pregnancy

Newborn Information

Full Term
Premature
Overdue

How many days/week premature/overdue?

Problem during birth?

Birth Weight

Length

Apgar Score

Condition

Good
Jaundice (yellow)
Respiratory Problems
Feeding Problems

Problems/Treatment after birth?

If yes, please explain (e.g. oxygen, intubation lights, surgery, or extended hospitalization required?)

Breastfeed?

If yes, what age stopped?

Has your child lost any skills?

If yes, describe in detail what skills were lost and when

Crawled on hands and knees (Approx. Age)

Weaned from pacifier (Approx. Age)

Walked without needing support (Approx. Age)

Weaned from bottle (Approx. Age)

Spoke first real words(Approx. Age)

Toilet trained (Approx. Age)

Combined 2-3 words (Approx. Age)

Played peek-a-boo (Approx. Age)

Pointed in order to request or draw attention to object

Does your child receive any therapeutic or educational services

Social Worker (Name)

Social Worker (Best Contact info)

Speech-Language Pathologist (Name)

Speech-Language Pathologist (Best Contact info)

Occupational Therapist (Name)

Occupational Therapist (Best Contact info)

Physical Therapist (Name)

Physical Therapist (Best Contact info)

Literacy Specialist (Name)

Literacy Specialist (Best Contact info)

Deaf Educator (Name)

Deaf Educator (Best Contact info)

Counseling Mental Health (Name)

Counseling Mental Health (Best Contact info)

Behavioral Therapy (Name)

Behavioral Therapy (Best Contact info)

Other (Name)

Other (Best Contact info)

Current School

Grade

Does your child have an individualized education or family plan (504 Plan, IEP or IFSP)

Does your child receive the following services through the educational plan?

Special Education or Resource Teacher (Name)

Special Education or Resource Teacher (Best Contact info)

Speech-Language Pathologist (Name)

other DESCRIBE Specialist

Speech-Language Pathologist (Best Contact info)

Occupational Therapist (Name)

Occupational Therapist (Best Contact info)

Physical Therapist (Name)

Physical Therapist (Best Contact info)

Literacy Specialist (Name)

Literacy Specialist (Best Contact info)

Deaf Educator, Aural Rehabilitation Specialist (Name)

Do you have concerns about your child’s ability to read/write or learn at school?

Yes
No
My child is not in school yet

My child is

Is doing as expected in school
Is starting to fall behind in school
Has been identified with a learning disability and is receiving services at school

Please describe your current concerns about your child’s ability to read/write/learn?

Pranamind Child Intake Form

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