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.

First Name

Last Name

Phone *

Email *

Occupation

Address

Street Address

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Postal code

Relationship to Patient *

Relationship to Patient

Mother
Father
Legal Guardian
Other
No elements found. Consider changing the search query.
List is empty.

Patient Details

Patient's First Name

Patient's Last Name

Patient's Sex

Male
Female
Prefer Not to Say
No elements found. Consider changing the search query.
List is empty.

Patient's School

Patient's Grade

Patient's Date of Birth

Additional Parent

Additional Parent's First Name

Additional Parent's Last Name

Additional Parent's Relationship to Child

Mother
Father
Legal Guardian
Other
No elements found. Consider changing the search query.
List is empty.

Additional Parent's Email

Additional Parent's Phone

Additional Parent's Occupation

Additional Parent's Address If Different

Additional Parent's Date of Birth

Names and Ages of Siblings

Referral Source

Reason For Referral

Physician

Medical Problem

Medications

Has the patient previously had a consultation or evaluation? If yes, please provide the name of the provider and the date.

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.

Onboarding Signature *

Clear

Developmental And Social History

Were there problems during your pregnancy with this child? If yes, please describe.

Problems during delivery? If yes, please describe.

Birth weight

Any illnesses during the newborn period? If yes, please describe.

Please indicate if any of the following:

Colic

Diarrhea

Excessive crying

Feeding problems

Excessive vomiting

Other problems or illness during the first year?

In general, was the child: an “easy” baby or a “difficult” baby?

Easy

Difficult

At what age did the child walk alone?

At what age was the child toilet trained for bowel movements?

At what age was the child toilet trained for bladder control?

At what age did the child start speaking in simple sentences?

Does the child have issues with wetting?

Yes

Does the child have issues with soiling?

Yes

How often does the child have wetting accidents during the day?

How often does the child have wetting accidents at night?

Medical History

Any illness other than normal childhood diseases?

Operations/Hospitalizations (Dates & reason for)

Select all that apply

Allergies

Headinjuries

Convulsions/seizures

Chronicearinfections

Frequent Colds

Eyeproblems

Is child currently on medication? If yes, please provide name of medications:

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.

Preschool Learning

Good

Average

Poor

Preschool Behavior

Good

Average

Poor

Kindergarten Learning

Good

Average

Poor

Kindergarten Behavior

Good

Average

Poor

Grades 1-3 Learning

Good

Average

Poor

Grades 1-3 Behavior

Good

Average

Poor

Current Grade

Current Grade Learning

Good

Average

Poor

Current Grade Behavior

Good

Average

Poor

Has your child repeated any grades? If yes, please specify which grade(s):

Is child working at grade level?

Yes

Have teachers described any of the following classroom problems?

Restless, overactive, out of seat

Inattentive, daydreams, off-task

Doesn’t finish work

Impulsive, can’t wait turn

Doesn’t do homework

Easily upset, “flies off the handle”

Work sloppy, careless

Needs much attention from teacher

Bothers other children

Uncooperative with teacher

Describe any other school-related problems

Habits

Temper tantrum

Low frustration tolerance

Accident-prone

Excessively active

Short attention span

Poor memory

Unusual fears

Interrupts frequently

Frequently disobeys

Clumsy

Heedless of danger or consequences

Stealing

Fighting

Poor self-esteem

Describe how child gets along with mother

Describe how child gets along with father

Describe how child gets along with siblings

Does your child have friends, and are they primarily older, younger, or the same age as your child?

Family History

Describe any psychiatric problems, drug abuse, or alcoholism in immediate family and extended family (include grandparents, cousins, etc.)

Has either parent or any of child’s blood relative had a problem similar to child’s?

How would you describe your marriage?

Do both parents agree concerning child’s problem, discipline?

Major Areas of Concern

What is child’s problem?

Has child had psychological testing in school or through a clinic?

Has child been treated for this problem before? Describe