Intake Form
Parent 1 Relationship to Client
Parent's Marital Status
Parent 2 Relationship to Client
Family Members Living in the Home
Providers
Reason for Seeking Treatment
Developmental History
Where any of the below used during the pregnancy
Please Select Any Developmental Milestones That Your Child Met
Please check any problems your child had/has as an infant or young child?
Medical History
Females
Social History
Academic History
Family History

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