Intake Form Full Name* First Last Preferred Name First Gender* Male Female Date of Birth* MM slash DD slash YYYY Place of Birth Person Completing this Form* First Last Relationship to Child* Phone*Primary Doctor Doctor's Phone NumberMother's Name First Last Mother's Place of Employment Mother's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mother's Email Father's Name First Last Father's Place of Employment Father's Address (if different from mother's) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Email Insurance Provider* Member ID* Name of Insured* First Last Insured's Date of Birth* MM slash DD slash YYYY Child Lives With (Select One):* Birth Parents Adoptive Parents Foster Parents Parent and Step-Parent One Parent Other children in the family:Please list children by name and provide their age, sex, grade and whether there is a history of speech or hearing problems.Child's Race/Ethnic Group: Caucasian, Non-Hispanic Hispanic African-American Native American Asian or Pacific Islander Is there a language other than English spoken in the home? Yes No If yes, what language? Does the child speak the language? Yes No Who can we thank for telling you about our practice? First Last Do you want a copy of our report sent to the doctor listed above? Yes No To what other professional persons or agencies do you want a report sent to? Pregnancy and Birth HistoryWas the pregnancy with this child planned? Yes No Month of pregnancy when started prenatal care Mother's age during pregnancy Which pregnancy was this for the mother (1st, 2nd, etc...)? Mother's health during pregnancy Good Fair Poor Did mother drink alcohol during pregnancy? Yes No If yes, what type of alcohol and how often? Did mother use any drugs during pregnancy? Yes No If yes, what kind of drugs and how often? Did mother smoke cigarettes during pregnancy? Yes No If yes, how often and how many packs a day? Did mother take any prescribed medications or vitamins during her pregnancy? Yes No If yes, please explain:How much weight did mother gain during pregnancy? Did mother have any complications during the pregnancy? Yes No If yes, please explain:List all pregnancies of the biological mother (include year, length of pregnancy, birth weight, difficulties during pregnancy, difficulties at birth and whether or not the child is living)Where was the child born?HospitalHomeOtherName of Hospital Location of Hospital City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Length of Pregnancy Length of Labor Labor was: Normal Difficult Please Explain:Type of Delivery:Natural (vaginal)C-SectionForcepsVacuumBaby's position: Head down (vertex) Legs or bottom down (breech) Baby's Apgar scores, if known: Were there any problems during labor and/or delivery? Yes No Please explain:Birth Weight: Birth Length: Birth Head Circumference: Duration of Mother's Hospital Stay and Duration of Baby's Hospital Stay? Were there any problems with mother or baby when in the hospital? Yes No Please explain:Baby passed newborn hearing screening?* Yes No Was baby breast fed, bottle fed, and/or tube fed? At what age was each method completed?Any hospitalizations since birth?* Yes No Please explain:Any operations since birth?* Yes No Please explain:Over the past 12 months, child's general health has been:* Good Fair Poor Over the past 12 months, have you noticed any worsening of your child's health? Yes No Please explain:Do you have any worries about your child's health? Yes No Please explain:Please list any allergies to food or medications:*Please type 'not applicable' if there are none.Child's Health HistoryIf your child has had any of the following, please check and explain when it occurred:Neurological/musculoskeletal Head injuries Dizzy spells Seizures or epilepsy Frequent Headaches Poor coordination Weakness Speech defects Meningitis or encephalitis Loss of consciousness, coma, fainting Sudden episodes of staring, confusion, altered awareness or responsiveness Excessive fatigue or daytime sleepiness Unusual movements (tremors, shaking, jerking, tics) Unusual walk or balance Frequent stuttering or stammering If you marked any of the above boxes, please explain:Hearing Ear infections Ear tubes Hearing problems If you marked any of the above boxes, please explain:Date of most recent hearing exam, if applicable: MM slash DD slash YYYY Results of most recent hearing exam, if applicable: Vision Vision problems Wears glasses and/or contacts Eyes turning in or out If you marked any of the above boxes, please explain:Date of most recent vision exam, if applicable: MM slash DD slash YYYY Results of most recent vision exam, if applicable: Respiratory Frequent colds Asthma Sinus condition Chronic cough Hay fever Constant nighttime snoring or difficulty breathing If you marked any of the above boxes, please explain:Cardiovascular/Hematologic Heart murmur Heart disease Anemia (low blood count) If you marked any of the above boxes, please explain:Gastrointestinal Frequent diarrhea Constipation Excessive vomiting or dehydration Frequent stomach pains If you marked any of the above boxes, please explain:Genitourinary Urination in pants/bed Excessive urination Pain while urinating Unusual or strong odor to urine If you marked any of the above boxes, please explain:Growth/Nutrition Excessive weight gain Slow height gain Slow weight gain Difficulty feeding, chewing or swallowing If you marked any of the above boxes, please explain:Skin Severe, frequent or unusual skin problems or rashes Birthmarks (light, dark or red skin patches that were present at birth or developed later) If you marked any of the above boxes, please explain:Sleep Difficulty falling or staying asleep Experience nightmares, night terrors, sleep walking, sleep talking If you marked any of the above boxes, please explain:Other History of sexual abuse History of physical abuse Suspicion of alcohol or drug abuse If you marked any of the above boxes, please explain:Has this child ever had or is he/she currently receiving any type of professional mental health treatments? (e.g. psychotherapy, family counseling, etc.) Yes No Please explain:What medications is your child taking at this time?*Please list the name of medication, dosage, frequency, and any other information. Please type "not applicable" if there are none.Has your child ever had a reaction to any medications?* Yes No Please explain:*Are the child's immunizations up to date?* Yes No If not, please explain:*Family HistoryAre the birth mother and father related in any way? (1st cousins, 2nd cousins, etc.) Yes No Please explain:Does anyone in the family have any of the following conditions? Check all that apply, past or present.Anyone in the family refers to the child's mother, father, sibling, mother's family, or father's family. Mental retardation Learning disorder Did not graduate from high school Aggressive or violent Attention problems; hyperactivity Depression Suicide attempts Anxiety disorder/panic attacks Psychosis or schizophrenia Obsessive-Compulsive Disorder Alcohol or drug abuse Trouble with the law; arrested, incarcerated Physical abuse Sexual abuse Tics or Tourette Syndrome Behavior problems as a child Seizures Autism Birth defects or familial disorder Cerebral Palsy Hearing problem; deafness Vision problem; blindness You selected "Mental Retardation" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Learning Disorder" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Did not graduate from high school" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Aggressive or violent" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Attention problems; hyperactivity" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Depression" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Suicide attempts" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Anxiety disorder/panic attacks" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Psychosis or Schizophrenia" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Obsessive-Compulsive Disorder" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Alcohol or drug abuse" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Trouble with the law; arrested, incarcerated" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Physical abuse" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Sexual abuse" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Tics or Tourette Syndrome" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Behavior problems as a child" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Seizures" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Autism" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Birth defects or familial disorder" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Cerebral Palsy" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Hearing problem; deafness" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family You selected "Vision problem; blindness" above, please select all of the family members that this applies to: Mother Father Sibling Mother's Family Father's Family Any other significant family history the therapist should be aware of? Yes No Please explain:School HistoryWhat school/daycare does your child attend?* Teacher's name What grade is he/she in? Type of classroom: Regular Special Education Number of children in the class:Has your child ever skipped or repeated a grade? Yes No Please explain:Does your child receive therapy services (ST, OT, PT) at school?* Yes No Does your child have an IEP or 504 plan?* Yes No What are your child's strengths and/or best subjects?Is your child having difficulty with any subjects?Is your child receiving help or tutoring in any subjects?What activities does your child like to engage in? What do they like to play with? What motivates this child?What type of discipline do you use at home?Is there any other information regarding your child that you would like to share with Jubilee Therapy?
