Your Details (Parent or Guardian)
Please fill out this form as accurately as possible before your appointment. If you prefer, you can print the documents and bring a physical copy instead: Download Here.
Patient Details
Additional Parent
By submitting this form, I authorize Child Developmental & Diagnostic Center to charge the card on file for one-time visits, evaluations, and subscriptions. I consent to the staff providing care, evaluations, and treatment for the patient listed and confirm both parents/guardians listed are authorized to discuss the patient’s care. I agree to the clinic’s terms andpolicies and release the center and its staff from any claims related to the services provided.
Developmental And Social History
Medical History
School History Section
For each grade level, rate your child’s performance in Learning and Behavior as Good, Average, or Poor by selecting the appropriate option.
Family History
Major Areas of Concern