230 Farmington Ave, Farmington, CT 06032
www.thetalcottcenter.com
[email protected]
CONFIDENTIAL PERSONAL HISTORY.
Today’s Date: _____________________
IDENTIFYING INFORMATION:
Child’s Name: _____________________
Address: __________________________
City, State, Zip: _____________________
_________________________________
School: ___________________________
Grade: ______
Completed by: ___________________________
Date of Birth:______ Age:__________________
Gender:__________ Ethnicity_______________
Primary language spoken at home:___________
Names/Ages of Siblings:___________________
_______________________________________
Medical Precautions/Allergies:______________
_______________________________________
CONTACT INFORMATION:
Mother’s/ Guardian’s Name: __________
Address:___________________________
__________________________________
Home#:__________Cell#:_____________
Email Address:______________________
Add email address to Talcott mailing list: Yes ,No
Occupation:________________________
Place of employment:________________
__________________________________
Work#:____________________________
Please check if insurance carrier -DOB_____
Insurance ID: Number___________________
Father’s/ Guardian’s Name:________________
Address:________________________________
_______________________________________
Home#:____________Cell#:________________
Email Address:___________________________
Add email address to Talcott mailing list: Yes,No
Occupation:_____________________________
Place of employment:_____________________
_______________________________________
Work#:_________________________________
Please check if insurance carrier -DOB______
Insurance ID: Number_____________________
Child’s Primary Care Physician:__________
___________________________________
Phone#:____________________________
Address:____________________________
Emergency Contact:_______________________
Relationship/ Phone#:_____________________
How did you hear about The Talcott Center?___
_______________________________________
Phone: (860) 674-1824
Fax: (860) 674-1836
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PERSONALITY PROFILE:
Please identify your child’s gifts/strengths- __________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are the presenting problems for your child? Please describe-(All categories below may not apply)
Academic:
_____________________________________________________________________________________
_____________________________________________________________________________________
Activities of daily living (i.e. dressing, eating):________________________________________________
_____________________________________________________________________________________
Sensory processing:
_____________________________________________________________________________________
_____________________________________________________________________________________
Motor Development:
_____________________________________________________________________________________
_____________________________________________________________________________________
Play: _________________________________________________________________________________
_____________________________________________________________________________________
Language Development: _________________________________________________________________
_____________________________________________________________________________________
Social Skills: ___________________________________________________________________________
_____________________________________________________________________________________
Other:
_____________________________________________________________________________________
_____________________________________________________________________________________
What do you hope to gain from child’s evaluation/treatment at The Talcott Center?
_____________________________________________________________________________________
_____________________________________________________________________________________
BIRTH HISTORY:
Pregnancy1. Where there any injuries/illnesses during pregnancy? Yes□ No□
Describe:
______________________________________________________________________________
2. Where there any shocks or unusual stressors during pregnancy? Yes□ No□
Describe:
______________________________________________________________________________
Phone: (860) 674-1824
Fax: (860) 674-1836
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3. Where any medications utilized during pregnancy? Yes□ No□
Describe:
______________________________________________________________________________
Describe:
______________________________________________________________________________
4. Any complications present during labor or delivery? Yes□ No□
Describe: ______________________________________________________________________
Length of labor: _______________
Premature: Yes□ No□
Weeks of gestation: ____________
Forceps used: Yes□ No□
Caesarean birth: Yes□ No□
Birth injuries: Yes□ No□
Intensive Care Required? Yes□ No□
Comments: ____________________________________
Comments: ____________________________________
Birth weight: ___________________________________
Suction used: Yes□ No□
Reason: _______________________________________
Describe: _____________________________________
Duration: ________________ Reason: ______________
Adoption –
Age when adopted: ______________________Adopted from: __________________________________
Describe the circumstances surrounding your child’s adoption: __________________________________
_____________________________________________________________________________________
Child’s response to their new home/ family: _________________________________________________
_____________________________________________________________________________________
Is your child aware of his/her adoption? Yes□ No□
MEDICAL HISTORY:
Does your child have a formal diagnosis? Yes□ No□
Diagnosis: ______________________________
Professional who diagnosed your child: ___________________Date of diagnosis: ___________________
Is there a family history of the same diagnosis, or similar diagnosis? Yes□ No□ Whom? _____________
Please check and describe all applicable, providing dates as known:
Ear infections? Yes□ No□ ___________
Tubes? Yes□ No□ _______________________________
Casts/ Orthotics? Yes□ No□ _________
Surgery? Yes□ No□ _____________________________
Seizures? Yes□ No□ ________________
Serious Injuries: Yes□ No□ ________________________
Serious Illness? Yes□ No□ ____________
Other: ________________________________________
Are there any other medical illnesses or conditions which your child has been diagnosed with? Yes□ No□
Please describe: _______________________________________________________________________
Phone: (860) 674-1824
Fax: (860) 674-1836
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Please list any medications your child has taken in the past or is taking presently:
Medication: _____________ Purpose: _______________ Dates Taken: ________Freq/ Dose: _________
Medication: _____________ Purpose: _______________ Dates Taken: ________Freq/Dose: __________
Medication: _____________ Purpose: _______________ Dates Taken: ________ Freq/Dose: _________
Medication: _____________ Purpose: _______________ Dates Taken: ________ Freq/ Dose: _________
PREVIOUS TESTING AND TREATMENT:
Has your child had any previous assessments and/or treatment? Please attach recent and relevant
reports.
ASSESSMENTS
TREATMENT
YES NO Professional/Date/Location
Yes No Professional/Date/Location___
Speech
□ □ __________________________
□ □ ________________________________
Audiological
□ □ __________________________
□ □ ________________________________
Educational
□ □ __________________________
□ □ ________________________________
Psychological □ □ __________________________
□ □ ________________________________
Neuropsch.
□ □ __________________________
□ □ ________________________________
Behavioral
□ □ _________________________
□ □ ________________________________
Occ.Therapy □ □ __________________________
□ □ ________________________________
Phy. Therapy □ □ __________________________
□ □ ________________________________
Vision
□ □ __________________________
□ □ ________________________________
Other:
□ □ __________________________
□ □ ________________________________
Please list all current services that your child is receiving from their school district:
_____________________________________________________________________________________
_____________________________________________________________________________________
Does your child receive/require 1:1 paraprofessional support within their educational program?
Yes□ No□
DEVELOPMENTAL MILESTONES:
(Please provide approximate ages if remembered)
Roll over: ______________ Sit alone: _____________ Crawl: ______________ Walk: ________________
Run: __________________ Toilet Trained: __________ Say words: _________ Say Sentences: ________
Chew solid food: ________Drink from a cup: _________ Feed self with utensils: ____________________
Was crawling phase brief: Yes□ No□/ Absent Yes□ No□:
Hand Dominance: Right□ Left□
Does your child have any feeding concerns? Yes□ No□
Is your child a picky eater? Yes□ No□
Describe eating/feeding habits or concerns noted: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone: (860) 674-1824
Fax: (860) 674-1836
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How does your child handle transitions (unexpected or planned changes in routines)? _______________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SPEECH AND LANGUAGE DEVELOPMENT:
How would you describe your child’s speech and language development? Typical□ Delayed□ Advanced□
Do you or others have difficulty understanding what your child says? Yes□ No□
What were your child’s first words and age(s) spoken? ________________________________________
Is there a language other than English spoken at home? Yes□ No□ If yes, which one? ______________
Does your child speak this language? Yes□ No□ Does your child understand this language? Yes□ No□
Who speaks this language at home? _______________________________________________________
How does your child usually communicate (gestures, single words, short phrases, sentences)? ________
_____________________________________________________________________________________
Is your child aware of, or frustrated by, any speech/ language difficulties? _________________________
_____________________________________________________________________________________
List approximate ages your child began to do the following:
Use single words (e.g., no, mom, doggie) ___________
Combine words (e.g., me go, daddy shoe) ___________
Name simple objects (e.g., dog, car, and tree) ________
Use simple questions (e.g., Where’s doggie) _________
Engage in a conversation ________________________
Does your child:
□ repeat words, sounds, phases over
□ understand what you’re saying
□ Point to common objects upon request
□ Follow simple direction
□ Respond correctly to yes/no questions
□ Respond correctly to who/what/why?
GOALS:
In order for The Talcott Center to best meet the needs of your child, please identify the goals for your
child’s program. Please be as specific as possible:
1) ______________________________________________________________________________
______________________________________________________________________________
2) ______________________________________________________________________________
______________________________________________________________________________
3) ______________________________________________________________________________
______________________________________________________________________________
4) ______________________________________________________________________________
______________________________________________________________________________
Phone: (860) 674-1824
Fax: (860) 674-1836
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