2021 New Client Information

NEW CLIENT INFORMATION
NEW CLIENT INFORMATION
Child's Name*

First NameLast Name
Child's date of birth*

MonthDayYear
Date
Parent/Caregiver Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Additional Phone Number

Area CodePhone Number
Please note that text reminders will go to

the primary caregiver's cell phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Additional Parent/Caregiver

First NameLast Name
Additional Parent/Caregiver Phone Number

Area CodePhone Number
Additional Parent/Caregiver Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

	Independent	Needs Assistance	Dependent
Takes off shoes and socks
Putting on shoes and socks
Taking off clothes
Putting on clothes
Fasteners (buttons, zippers)
Eating small foods (ie cheerios)
Eating with a spoon
Eating with a fork
Cutting with a knife
Drinking from a cup
Drinking from a straw
Toileting skills (cleaning himself)

	Yes	No	Sometimes
Respond to his/her name?
Point to objects when asked?
Follow simple directions?
Get objects from another room when asked?
Point to body parts when asked?
Point to pictures in books when asked?
Answer simple questions?
Point to family members when asked?
Understand prepositions (in, on, under, next to)?
Understand color & size words (red, big/small)?
Engage in pretend/imaginary play?
Socialize/play with other children?
Repeat sounds/words when speaking?
Have difficulty learning/retaining new information?
Have difficulty learning/using new words?

NEW CLIENT INFORMATION