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  • Pregnancy/Birth History

  • Description of Child

  • Developmental History

  • Please list the child's age for meeting the following developmental milestones in years/months.

  • Has your child experienced exposure to trauma of any kind? Examples: witnessing a violent act such as domestic violence, witnessing a death or accident, sexual abuse, physical abuse, verbal abuse or shaming, bullying, drug or alcohol addiction in the home, natural death of a loved one, chronic illness of a loved one, etc.

  • Home Environment

  • Medical History

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  • Medications/Allergies

  • Questions/Concerns

  • Clear
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  • Should be Empty: