Please complete and submit. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your child.
Please answer the following questions to the best of your ability:
Please tell us about your occupation.
12. Family Health
17. Medical History: Please indicate anything notable about the child’s medical status, including neurological problems and allergies.
Check the descriptions which specifically relate to your child.
Who handles responsibility for your child in the following areas?
If the child is involved in a vocational program or works a job, please fill in the following: