Patient Registration Form

Person Completing This Form:

Name:

Relationship to the Client:

Client

Father

Mother

Other

Please specify the relationship to the client:

Mobile:

Email: *

Client Information

Client First Name:

Last Name:

Preferred Name (If different than first name):

Gender:

Male

Female

Other

Date of Birth:

Age:

Nationality:

Mobile (if applicable):

Email (if applicable):

CPR/Passport Number:

CPR/Passport Expiration Date:

(If passport) Country of Issue:

First/Home Language:

Other Languages Spoken (optional):

Father:

First Name:

Last Name:

Mobile:

Email:

Occupation:

Employer:

Mother:

First Name:

Last Name:

Mobile:

Email:

Occupation:

Employer:

Address:

Contact Information

Primary Contact

Please specify a primary contact person.

Mother

Father

Client

Other:

Name:

Relationship to client:

Mobile:

Email:

Emergency Contact

In case of an emergency, who should be contacted first

Mother

Father

Client

Other:

Name:

Relationship to client:

Mobile:

Email:

In case of an emergency, if the primary emergency contact cannot be reached, who should be contacted?

Mother

Father

Other:

Name:

Relationship to client:

Mobile:

Email:

In case of an emergency, if the primary emergency contact cannot be reached, who should be contacted?

Mother

Father

Other:

Name:

Relationship to client:

Mobile:

Email:

Client Background

Medical Background

Primary physician/Medical center

Physician name:

Medical center/Hospital name:

Location/Branch:

Contact information:

Current medical diagnoses:

Current medications (please include medication names, dosages, and, if applicable, date of discontinuation):

Allergies:

History of seizures (If so, please include how often they occur and when the last occurrence was):

Surgeries or major medical history:

History of seizures (If so, please include how often they occur and when the last occurrence was):

Educational Background

Is the client currently enrolled in school? If yes:

School name:

Grade level/year:

Does the client have a current IEP?

Does the client currently have a shadow at school?

If yes, is the shadow hired privately or by the school?

Is the client receiving additional services or accommodations in the school?

List:

Other schools the client has previously attended:

School name:

Dates of attendance:

Start:

End

Grade level/year:

Reason for leaving the school:

Client can click to add additional schools

School name:

Dates of attendance:

Start:

End

Grade level/year:

Reason for leaving the school:

School name:

Dates of attendance:

Start:

End

Grade level/year:

Reason for leaving the school:

Evaluations/Assessments

Has the client ever been formally diagnosed/evaluated/assessed by a Psychologist, Psychiatrist, Occupational Therapist, Speech Therapist, Applied Behavior Analyst, etc.? If yes:

Provider name:

Assessment/Evaluation name or purpose:

Date conducted:

Summary of results:

Client can click to add additional evaluations/assessments

Provider name:

Assessment/Evaluation name or purpose:

Date conducted:

Summary of results:

Provider name:

Assessment/Evaluation name or purpose:

Date conducted:

Summary of results:

Provider name:

Assessment/Evaluation name or purpose:

Date conducted:

Summary of results:

Other formal diagnoses (if not listed above):

Intervention/Therapy Background (ABA, Speech, Occupational Therapy, Physical Therapy, etc.)

Other current intervention/therapy providers

Provider name:

Service type:

Date service began: