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New Client Form


This form has been designed to ask questions about your child’s history and current symptoms. This form will provide useful information for assessment and treatment. Please fill out form completely. If you have questions, please e-mail

Note: If your child has been previously evaluated, please provide a copy of the report.

Over the last two weeks, how often have you noticed your child may have been bothered by any of the following problems?
Please answer the questions below using the option that best describes what you may have noticed in your child over the past six months.
I understand that it is important to provide accurate information in order to tailor treatment and assessment to meet my child’s needs. This information is correct as I have described it.