Bridges Educational Corporation | New Client Information

Loading

New Client Information
Thank you for choosing Bridges Educational Corporation. Please complete the following form so that we have as much information as possible before we meet you and your child. You will receive a call shortly to schedule your appointment. We look forward to meeting you at your first appointment.

1. Identifying Data
Child's Name:


Address:



Telephone Info:

Father's Phone:

Mother's Phone:

Mother's Email:

School Information:


Child's Sex:

Male Female

Child's DOB:

Father's Name:

Mother's Name:

Stepfather's Name:

Stepmother's Name:

Person Filling Out Form:

2. History
With whom has child lived most of his or her life:

With whom is child currently living:

List 6 approved designated caregivers for your child:
1.

2.

3.

4.

5.

6.

If child is living or has lived with person (s) other than parents:

What is or was the length of time of this arrangement?

Under what conditions were these arrangements made?

Who has legal custody of the child?

If either parent is not in the home, where does he/she live?

Mother:

Name:

Address:

Age:

Father:

Name:

Address:

Age:

If both parents are employed, who cares for the child during the day?

List child's brothers and sisters:

First Sibling Name:
School/Occupation:
Age:

Sex:
Male
Female

Sibling Relationship to Child:

Full	Half
Step	Adopted

Living at Home:
Yes
No

Second Sibling Name:
School/Occupation:
Age:

Sex:
Male
Female

Sibling Relationship to Child:

Full	Half
Step	Adopted

Living at Home:
Yes
No

Third Sibling Name:
School/Occupation:
Age:

Sex:
Male
Female

Sibling Relationship to Child:

Full	Half
Step	Adopted

Living at Home:
Yes
No

Fourth Sibling Name:
School/Occupation:
Age:

Sex:
Male
Female

Sibling Relationship to Child:

Full	Half
Step	Adopted

Living at Home:
Yes
No

Fifth Sibling Name:
School/Occupation:
Age:

Sex:
Male
Female

Sibling Relationship to Child:

Full	Half
Step	Adopted

Living at Home:
Yes
No

Which language(s) other than English are regularly spoken in the child’s household?

What types of moves have occurred in the last 5 years?

Lived in Same Place
Moved Between States (Number of Times:)
Moved Between Cities (Number of Times:)
Moved Within City (Number of Times: )

3. Birth Information

Age of mother at time of child’s birth?

Problems during pregnancy with this child:

None
Unusual Swelling
Unusual Weight Gain   - How Much:
High Blood Pressure
Infection    What Kind:
Bleeding
Unusual Vomiting
Medicines taken during pregnancy
        List Names and Reasions for taking:

Disease or exposure to contagious disease such as measles
        List Type:

Persistent emotional stress and/or anxiety
        Describe:

Other
        Describe:

Did the mother have medical care while she was pregnant with this child:
Before 3rd Month
After 3rd Month
None

Was pregnancy:
Full Term (9 Months)
Premature

Delivery occurred during the month of pregnancy.

How long was labor?

Labor was:
Natural
Induced

Were there any complications during labor:
No
Yes   Explain:

Was delivery at:
Home
Hospital
Other

Was delivery attended by:
Physician
Midwife
Other

Was delivery normal?

Yes

No

Forceps Used
Breech Birth
Cesarean Performed
Multiple Births How Many?

Child's Birth Weight?

Were there problems with child in the hospital before coming home?
No Problems
Infarction What Type?
Convulsion
Other Explain:

4. Developmental Information

During infancy, were any of the following problems present?
Difficulty Sucking
Choked Easily
Vomited or spit up frequently
Child was limp
Child was stiff
Unusually nervous
Unusually jittery
Excessive crying
Difficulty sleeping
Colic after 3 months of age
Difficulty chewing
Allergies
Breath holding spells
Other:

At what age did each of the following occur?
  Smiled
  Sat without support
  Walked alone
  Spoke first word
  Used two- or three-word sentences
  Was completely weaned
  Started toilet training

Which hand does the child prefer?

Right

Left

Is this preference consistent?

Yes

No

How would you compare this child’s motor development (walking, etc.) to that of his siblings?

Same

Better

Not as good

Language Development:

Is your child using words at this time?
Yes How Many?
No

How would you compare this child’s language development with that of the siblings?

Same Better Not as good

Has the child received speech therapy?
Yes
No

If yes, At what age?

For how long?

Where?

5. Medical History

What is the child’s present health?

When was the child’s most recent physical exam?

Is child now taking any medication?
No
Yes explain

Does child have any allergies?
No
Yes explain

Has the child ever had dizzy spells, convulsions, or unconscious periods?
No
Yes

Has the child ever had an EEG?
No
Yes

At what ages?

Why was an EEG recommended?

Results if known?

Does the child have any hearing difficulties?
No
Yes   explain

Does the child have any vision difficulties?
No
Yes   explain

Does the child have any physical disabilities or other limitations?
No
Yes   explain

Describe any behavior challenges your child has: