Child Assessment Form
Please tell us a little about your child by completing and submitting the form below. All information provided is held in strict confidence and will never be given out. Fields denoted with an asterisks (*) are required.

Name* Address* City* State/Province* Zip Code* Country* Telephone Number* E-Mail Address* Child's Name* Child's Age* Sex* Male Female How did you find out about us? Please Select One ---->DoctorEmail ListFriendGoogleMagazine/NewspaperNews GroupRadioMagazine/NewspaperTherapistWebsiteOther: Complete below Other Now, please give a brief history of your child: including pregnancy, birthing, birth defects, serious illnesses, surgeries, diagnoses, and any current medications Physical Aspects History of seizures? History of ear infections? Repetitive rounds of antibiotics? Child appears not to feel pain? Irregular sleep patterns? Are dietary modifications in place? Issues with bed-wetting? Difficulty with toilet training? Tactile defensiveness (clothing, food textures)? Appears clumsy or uncoordinated? Can child pedal or ride a bicycle? Difficulty with fine motor skills Any regression after immunizations? Any detoxifying or chelating procedures? Are there any digestion/elimination problems? Visual/Motor Skills Poor eye contact? Sideways gazing? Tracking problems? Strabismus? Difficulty catching a ball? Any vision correction? Does artwork look too primitive for age? Auditory/Language Was there any speech delay? Is speech now age appropriate? Are there central auditory processing issues? Are there sensitivity to sounds? Does child have a sense of rhythm? Behavioral Responses to Sensory Stimuli Overwhelmed in sensory-rich environments? Hyperactive? Under responsive to sensory stimuli? Any 'Self-stimming behaviors' present? Irregular sleep patterns? Hand-flapping? Toe-walking? Addictive tendencies to TV/computer games? Obsess with routines and/or repetitive patterns? Difficulty with transitions? Emotional Responses to Sensory Stimuli Difficulty showing affection? Shows lack of empathy? Has unreasonable fears? Has frequent meltdowns/tantrums? Angry and/or aggressive behavior? High anxiety? Often depressed? Night terrors? Has extreme shyness? Controls environment and manipulates people? Difficult relationships with peers? Missing social cues? Child feels he/she has no friends? Frequently teased by peers? Academic, Visual/Auditory Skills Difficulty making progress with handwriting? Difficulty concentrating and attending to tasks? Difficulty understanding symbols (shapes, numbers etc.)? Difficulty following multi-step oral directions? Difficulty learning to read? Poor comprehension when reading? Can child decode phonetically (sound out words)? Can child learn spelling words easily?