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Child Intake Form (2 of 2)

PHYSICAL DEVELOPMENT:
Medical Information
-Date -Name of Medication -Amount(ex -10 mg.) -Taken when: -Prescribed by: -Child’s reaction:
-Date -Name of Medication -Amount(ex -10 mg.) -Taken when: -Prescribed by: -Child’s reaction:
-Date -Name of Medication -Amount(ex -10 mg.) -Taken when: -Prescribed by: -Child’s reaction:
-Date -Name of Medication -Amount(ex -10 mg.) -Taken when: -Prescribed by: -Child’s reaction:
-Date -Name of Medication -Amount(ex -10 mg.) -Taken when: -Prescribed by: -Child’s reaction:
-Dates and grades Attended -Name of school -Address and Telephone no. -Behavior problems, if any
-Dates and grades Attended -Name of school -Address and Telephone no. -Behavior problems, if any
-Dates and grades Attended -Name of school -Address and Telephone no. -Behavior problems, if any
-Dates and grades Attended -Name of school -Address and Telephone no. -Behavior problems, if any
-Dates and grades Attended -Name of school -Address and Telephone no. -Behavior problems, if any
-Dates and grades Attended -Name of school -Address and Telephone no. -Behavior problems, if any
SOCIAL ADJUSTMENTS:
-Dates -Therapist’s name, address, phone -Results
-Dates -Therapist’s name, address, phone -Results
-Dates -Therapist’s name, address, phone -Results
-Dates -Therapist’s name, address, phone -Results
-Dates -Therapist’s name, address, phone -Results
-Dates -Therapist’s name, address, phone -Results
FAMILY HISTORY (to be filled out by each parent)