Child's Registration Form

Boo Boo, Co-Therapist

Date

Form Completed By:

Child's Name

Child's Age

Date Of Birth

Height

Weight

Current physical health problems/diagnoses

Past physical health problems/diagnoses

Current medications for physical health

Current mental health diagnoses

Past mental health diagnoses

Current medications for mental health problems

Current Allergies

Primary Caregivers’ Information

Please write the Name, Age, And occupation of all primary caregivers

Family Information

Other caregivers (daycare, family members, etc.)

Describe your spiritual belief system.

Others living at home

Please provide the Name, Age, and Occupation of others residing in the home.

Child History

What is the child’s relationship to caregiver? Birth child, adopted, step child, grandchild, etc.

If adopted, how many prior placements?

How old was the child when the child came to live with you?

History of abuse, neglect, trauma or significant separations

Child’s Current Developmental Functioning

Gross motor functioning and difficulties

Fine motor functioning and difficulties

Language functioning and difficulties

Intellectual functioning and difficulties

Sensory processing Issues

Fetal alcohol or drug affected?

Has child had any head injuries?

Encopretic (soils self)

Enuretic (wets self)

What therapies is child currently undergoing?

What therapies for above conditions has child undergone before?

Please describe areas of concern for which you are seeking treatment

Note: Please attach summaries of prior assessments relevant to this evaluation; attach any legal histories (arrests); attach any information regarding prior drug/alcohol/nicotine abuse.

School Information

School and School District

Grade

Any academic learning problems?

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