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APPLICATION

Child's Information
Child's Name:                  Birth Date: //      Gender:
Address:       City:
State:    Zip:       Phone #:
e-mail:   Pediatrician:
Please list any major medical problems:
Does your child have a developmental diagnosis? If yes, what is diagnosis?
Age of child at initial diagnosis: years Who made the diagnosis?
Family Information
Mother's Name:                        Birth Date: // 
Occupation:       Schooling:
Father's Name:                        Birth Date: // 
Occupation:       Schooling:
Marital Status: If other, explain:
Other Caregiver's Name:           Birth Date: // 
Occupation:       Schooling:
Names & Ages of siblings:
List the names of those living in the household other than the immediate family:
List the names of those living in the household other than the immediate family:
Educational Information
Is your child in a Birth to Three Program?           School District Program?
Agency or School Name:    District:
Address:       City:
State:        Zip:      
Age when first enrolled in either of the above? years    months
Number of hours your child spends in an early intervention program per week:
Is your child enrolled in a community preschool program?     
If “yes”, what are the days and times?

Therapies/Interventions

Therapy/Intervention

Agency

Start Date

Frequency

Session Length

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Please total the number of hours per week of all therapies outside of school:
Parent Involvement
Are you familiar with DIR / Floortime Techniques? 
Are you using these with your child? 
If yes, please estimate the number of hours per week:
Other Information
Is there anything else you would like to tell us about your child?