Back to Forms List Intake Sheet I. Child's Identification Information Name: Nickname: Sex: Birthdate: Name of school, if attending: II. Family Information: Parents or Guardians Name Address Place of Employment Work Phone Name Address Place of Employment Work Phone Single Married Divorced Separated Foster Parent Names and Ages of Other Children in Home: III. Emergency Contact Name Address Place of Employment Work Phone Name Address Place of Employment Work Phone IV. Play and Sociability How Does Your Child Get Along with Other Children? His/Her usual playmates are Girls Boys Older Younger What is usual size of your child's neighborhood playgroup? Previous Group Experience Outside of School Preschool Playgroup Sunday School Other If Other, Specify V. Personality and Emotional Development Is your child affectionate? YesNo To whom? Does he/she accept new people easily? Yes No What are your child's fears? Is your child usually happy? Yes No What nervous habits does your child have? VI. Discipline When you find it necessary to discipline your child, which parent usually does this and how? VII. Infants and Toddlers Has your baby had feeding problems? Yes No If yes, please explain Have you noticed any allergies or sensitivities to particular foods? Is your baby: Breast fed? Bottle fed? What food is your baby eating now? Fruits Vegetables Cereals Juices Meats Milk (Formula) Sleep habits during normal day: Does your child have "fussy" time? When? How do you handle "fussy" time? Do you have special ways of helping your baby got to sleep? If yes, how? Does your child use a pacifier or suck thumb/fingers? Has toilet training been attempted? Yes No What is used at home? Is baby's skin highly sensitive? Yes No What is used at home? How does your child relate to strangers? Is your child frightened by anything? VIII. Other Information: Please list some of your child's favorite: Snacks & Drinks: Games: Other Activities: Give any other information you believe will be helpful to us in understanding your child. Captcha Submit If you are human, leave this field blank. Δ
