background form

Thank you for helping us better understand your concerns. We look forward to providing services to your family. This form is to be used by families after receiving contact from our office indicating that your referral has been accepted. If you have not received a referral to our psychology department, please talk to your child's primary care physician.

If you have any questions, please contact us at 937-641-4040. We will call you within three days of the receipt of this form to schedule an appointment.

Today's Date:

Your Name:

Child's First Name:

Child's Last Name:

Child's Birthdate:

Child's Gender:

Address

address:

Address:

City:

State:

Zip:

Parent/Guardian Information:

parent/guardian Information:

Parents' or Guardians' Name(s) :

Best Phone Number:

Secondary Phone Number:

Email Address:

Parents' Marital Status:

Your Relationship to this Child :

Who has custody of this child?

Background Information:

background information:

Siblings' Names and Ages:

Other persons living in your child's home:

What concerns do you have about your child?

When were you first concerned about these issues?

Have you previously sought assistance for these concerns?

Is your child currently receiving services/treatment?

If YES, what is the name of that therapist?

Was the previous treatment helpful?

Developmental history

developmental history

Were there complications during pregnancy or the delivery of your child?

Did the mother require any medications during pregnancy?

At what age did your child:

Roll Over

Crawl

Walk

Use single words

Combine words

Become toilet trained

Do you have concerns about any of the following for your child?

do you have concerns about any of the following for your child?

Health issues?

Use of words (speaking ability, size of vocabulary, rarely speaks, etc.)?

Understanding of what others say (i.e. hearing abilities, comprehension level)?

Attention span?

Sleep patterns?

Trouble falling asleep?

Night time wetting?

Daytime wetting?

Bowel accidents?

Appetite?

Getting along with others?

Recent changes or family stressors (e.g., divorce, separation, loss of a loved one, loss of pet, family illness, parental job loss, trauma or abuse)?

If you answered "Yes" to any of the above, please explain:

School

school

Child's grade in school:

Name of school currently attending:

What grades does your child earn?

Has your child ever repeated a grade in school?

If YES, which grade?

Does your child receive any educational interventions?

If YES, what are they?

Does your child have an Individual Educational program?

If YES, please bring a copy of the IEP to your first visit.

Please describe your child's strengths, hobbies and interests.

Medications your child takes

medications your child takes

medication1

Re-order	medication	dose	how often	Weight	Operations
	medication	dose	how often	Item weight

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medication2

Re-order	previous medication	dose	how often	Weight	Operations
	previous medication	dose	how often	Item weight

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insurance information

Is your child covered by commercial insurance or Medicaid?

Name of insurance plan:

Policy #:

Name of insurance subscriber on this plan?

Relationship to the child?

Is this child covered by a 2nd insurance plan or Medicaid?

2nd name of insurance plan:

2nd policy #:

2nd name of insurance subscriber on this plan?

2nd relationship to the child?

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developmental history

do you have concerns about any of the following for your child?

school

medications your child takes

insurance information

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