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  • Thank you for taking the time to fill in the information requested on this form. By doing this, you will make it easier for us to get to know your child and his/her needs as well as formulate a treatment plan. If you are not sure of an answer, leave blank and we can discuss at the initial evaluation meeting. 

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  • Birth History

  • Communicaton (Receptive and Expresive Language):

  • Developmental & Social History

    Please answer when child met developmental milestones and describe issues with school and behavior.
  • Medical History

  • Current Behaviors


  • Family History

  • Family Relations

  • Educational History

  • Social Emotional Development

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  • Should be Empty: