Child Case History Child Case History Child's Name DOB Grade Level Parent's Names Home Ph. Work Ph. Mother's cell Driver's License # Father's cell Driver's License # Address City State Zip Parent(s) email address(es) Name of School Teacher Pediatrician Dentist (if applicable) Insurance Provider Address Phone Medical History/Allergies Describe Concerns Describe Development Milestones (age talk, walk, etc.) Academic Performance Insurance Carrier Policy Holder's Name Date of Birth Group # ID # Your monthly statement will list a treatment and diagnosis code necessary to file insurance. If you would like additional assistance in filing insurance, please see the office manager. Do you object to the release of relevant information concerning your child's progress (to teachers, pediatricians or insurance companies)? Yes No How were you referred to us? Name Date Send
