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Social History Form

If you are interested in a pre-screening, please complete the Social History Form

Client Info

Date of Birth
Month
Day
Year

Emergency Contact

Insurance Information

Referral Source

Medical History

Current Symptoms/Concerns

Developmental History:

Prenatal/Birth History:

Milestones:

Early Childhood/Preschool:

Educational Environment:

Educational/ Goals:

Speech, Occupational Therapy, and Physical Therapy Specific Questions:

Speech Therapy:

Swallowing difficulties or concerns?
Yes
No
Any recent changes in communication abilities?
Yes
No

Occupational Therapy

Fine motor skills concerns?
Yes
No
Sensory concerns (hypersensitivity, hyposensitivity)?
Yes
No
Activities of daily living (ADLs) concerns (e.g., dressing, grooming, feeding)?
Yes
No

Physical Therapy

Gross motor skills concerns?
Yes
No
Mobility challenges or limitations?
Yes
No
Pain or discomfort during movement?
Yes
No

Social/Emotional/Behavioral:

Social/Emotional History:

Any behavioral concerns or challenges?
Yes
No

Family/Support System:

Client Goals:

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