Child Medical History Questionnaire

Your information helps us better understand and support your child's needs. All data is kept private and secure.

Required Information: Please ensure you provide your contact email, phone number, and attach the client's psychological evaluation to complete this form.

Basic Information

Child's Name *

Age *

Date *

Form Completed By *

Relationship to Child

Are you the legal guardian?

Client's Insurance

Member ID

Your Email Address *

Your Phone Number *

Medical History

Primary Care Physician (name, contact number, address, email)

Does your child have any allergies? If yes, please list below.

If life threatening, please list below.

Instructions for allergic reactions

Dietary restrictions, special diet

Social History

Primary language spoken in the home. List any other languages spoken.

Legal issues that may impact treatment (divorce, custody, child services open cases, etc.)

Spiritual needs that may impact treatment?

Cultural variables that may impact treatment?

School Information

School Setting:

Name of school/daycare

Grade

Address of school/daycare

Contact name of school/daycare

Teacher's name

Teacher's phone number

Living Situation

Child resides with?

Behavioral Health History

Name of the Provider:

Email Address:

Phone Number:

I would like Klubhouse Therapy Services to contact this provider.

Therapeutic Intervention:

Response to the Intervention:

Community Resources

(Support Groups, Social Services, School Based Services, Other Therapies such as OT/PT/SPEECH etc.)

Name of the Provider:

Email Address:

Phone Number:

I would like Klubhouse Therapy Services to contact this provider.

Notes:

Additional Documents

Client's Psychological Evaluation Information

Upload Psychological Evaluation Document (PDF, DOC, DOCX - Max 5MB)

Accepted formats: PDF, DOC, DOCX. Maximum file size: 5MB.

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