Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Client contact information
Last name
First Name
Preferred Name
Street address
City
State
Email address
Primary phone
land line
mobile
Zip code
County
Gender
Date of Birth
land line
Alt. phone
mobile
Preferred language
Preferred method of communication (please select)
primary phone, voice
May we leave a message on your voicemail? (Please circle one.) Yes No
text
e-mail
Parent/Primary caretaker (Mother) contact information (if applicable)
Last name
First Name
Preferred Name
Street address (if different from client)
City
State
Email address
Primary phone
land line
mobile
Zip code
County
Gender
Date of birth
land line
Alt. phone
mobile
Preferred language
Preferred method of communication (please select) primary phone, voice
May we leave a message on your voicemail? (Please circle one.) Yes No
text
e-mail
Parent/Primary caretaker (Father) contact information (if applicable)
Last name
First Name
Preferred Name
Street address (if different from client)
City
State
Email address
Primary phone
land line
mobile
Zip code
County
Gender
Date of Birth
land line
Alt. phone
mobile
Preferred method of communication (please select) primary phone, voice
May we leave a message on your voicemail? (Please circle one.) Yes No
Emergency contact
Primary phone
Preferred language
text
Relationship to client
land line
mobile
Alt. phone
land line
mobile
How did you hear about Next Right Steps? Is there someone we can thank for the referral?
e-mail
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
MEDICAL HISTORY
Please check any of the following professionals with whom you have had contact.
PEDIATRICIAN
See Currently
Name:
City/State:
Phone:
FAMILY DOCTOR
See Currently
Name:
City/State:
Phone:
NEUROLOGIST
City/State:
Phone:
EAR, NOSE & THROAT SPECIALIST
Phone:
Phone:
City/State:
Phone:
City/State:
Phone:
Phone:
City/State:
Phone:
City/State:
Phone:
Phone:
OCCUPATIONAL THERAPIST
Phone:
Name:
Phone:
Seen in the past
See Currently
Name:
City/State:
Phone:
Seen in the past
See Currently
Name:
City/State:
Phone:
Seen in the past
See Currently
Name:
City/State:
Seen in the past
See Currently
City/State:
OTHER (specify):
Seen in the past
See Currently
Name:
City/State:
DIETITIAN
Seen in the past
See Currently
Name:
City/State:
SOCIAL WORKER
Seen in the past
See Currently
Name:
PHYSICAL THERAPIST
Seen in the past
See Currently
Name:
SPEECH THERAPIST
Seen in the past
See Currently
Name:
City/State:
AUDIOLOGIST
Seen in the past
See Currently
Name:
PSYCHOLOGIST
Seen in the past
See Currently
Name:
PSYCHIATRIST
Seen in the past
See Currently
Name:
City/State:
DENTIST
Seen in the past
See Currently
Name:
City/State:
SURGEON
Seen in the past
See Currently
Name:
OPHTHALMOLOGIST
Seen in the past
Phone:
Seen in the past
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
Why are you seeking Next Right Steps services?
Problem(s) client is having at school/work:
Problem(s) client is having at home:
Describe clients health:
Does client have any medical conditions? Yes
If yes, please explain:
No
Does client take any medications and/or supplements?
If yes, please list:
Yes
No
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
Does client have any allergies?
If yes, please list:
Yes
No
List current therapies, if any:
Previous therapies you have done with client or for client, if any:
ABA (Applied Behavioral Analysis)
Acupuncture
Aqua Therapy (Water Therapy)
Art Therapy
Auditory Integration
Brain Balance
Chelation
Computer Aided Instruction
Feeding Clinic Therapy
Floortime
Hippotherapy (Equine Therapy)
Hyperbaric Therapy
Massage/Touch Therapy
Music Therapy
Occupational Therapy
Physical Therapy
Psychiatrist
Psychological Counseling
Sensory Integration Therapy
Social Skills Groups
Specialized Camps:
______________________________
______________________________
Speech Therapy
Video Modeling
Vision Therapy
Tutoring
o Private
o Company, i.e., Kumon, Huntington, etc. _____________________________
Other:
_____________________________________________________________________
_____________________________________________________________________
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
Based on your experience, what therapies have worked best? Please explain.
Based on your experience, what therapies have not worked? Please explain.
Is client currently or has client ever been involved in any activities outside of
school or formal therapy sessions, i.e. sports, community groups, etc.? Yes No
If yes, please list activities.
Clients sleep pattern (Please check all that apply.)
Normal
Sleep walking
Very sound
Sleep apnea
Restless
Night terrors
Nightmares
Difficulties falling asleep
Snoring
Difficulties staying asleep
Resists sleep
Other _____________________
Clients general appetite and eating habits (Please check all that apply.)
Good appetite
Normal eating patterns
Picky eater
Special/specific diet
Self-restricts food
___________________________
Poor eater
___________________________
Refuses to eat fruits and/or vegetables
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Parents present marital status:
Married
Separated
Divorced
Widowed
Never married
Unmarried, but in a
committed relationship
If married, number of years in present marriage: ___________ years
On a scale of 1-5, describe your present marriage: (Please circle)
1
Poor
2
Tolerate
each
other
3
Relatively
happy
4
Happy
5
Very
happy
If remarried since birth of client, how old was (s)he when you:
divorced? ____________________
remarried? ___________________
If separated/divorced, who has primary physical custody?
Stepparent or significant others name: _________________________________
Please write in name, relationship to client, and birthdate of all members living
in clients home(s). (Please specify where each member resides.)
Name
Relationship
Date of birth
Residence
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
Describe relationship with mother. What activities do you enjoy together?
Describe relationship with father. What activities do you enjoy together?
Describe the type of discipline used in the home. Is it consistent? Who
administers the discipline?
Describe relationship to siblings (Please check all that apply.)
Sibling rivalry
Conflictual
Close
Jealousy
Good
Relates well
Strained
Distant
with siblings
Notes on sibling relationships:
Do you use alternate care/respite care/child care arrangements? Yes
No
If yes, with whom? _________________________ how often? __________________
Are there any significant health, emotional, and/or behavioral problems with
other children in the family? Yes
No
If yes, please explain:
Birth order in family, i.e., first-born, middle child, baby, etc. _______________
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Clients birth history
Birth:
full term
premature
biological adopted surrogate
other _______________
Weeks gestation: _________________
Length of labor: __________________
Anesthesia used: __________________
Complications during pregnancy:
None
Diabetes
Bleeding
RH factor
Medication
Other
Toxemia
_________________________
Labor induced?
Yes
If yes, please explain:
No
Were there any problems or complications immediately after birth? Yes
If yes, please explain:
No
Apgar score (if known): ___________
Birth weight: _______________________
Was client placed in an incubator?
If yes, please explain:
Yes
No
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Early development
Please indicate any complications during infancy: (Please check all that apply)
Colic
Physical defects
Feeding difficulties
Rigid when held
Irritability
Sleep difficulties
Low birth weight
Other: ____________________
Please provide any further information about above complications, if any:
Please check the box if the milestones were reached by the time indicated:
Holds head up independently by 3-4 months
Begins crawling by 9-10 months
Says one word by 12 months
Walks without support by 18 months
Speaks 2-word sentences by 2 years
Speaks in multi-word sentences by 3 years
Potty-trained by 3.5 years
Dresses self independently by 5 years
Please indicate age achieved for milestones later than those above and any
issue(s) associated with the delay(s):
Describe client as a toddler:
Development compared to siblings or peers, if no siblings:
same
early
9
late
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
General history and information
Handed:
Left
Right
Mixed dominance (left/right)
Medical Issues:
High fevers
Frequent ear infections
Hearing impairment
Visual impairment
Visual impairment, wears glasses
Motor delays
Global developmental delays
Speech impairment, articulation difficulties
Speech impairment, receptive language delays
Speech impairment, expressive language delays
Other ______________________________________
None
Has client had any injuries or accidents, specifically, blows to the head? Yes No
If yes, please explain:
List any support networks, i.e. extended family, friends, support groups,
Church, Temple, Mosque, etc. and how often is contact made?
Attendance of religious services:
Yes, regularly attend
Yes, occasionally attend
Yes, seldom attend
No
Believe in a higher power, but do not attend a church
Never attended Church, Temple, Mosque, etc.
If affiliated, name of Church, Temple, Mosque _____________________________
10
(770) 765-NEXT (6398)
www.nextrightsteps.com
info@nextrightsteps.com
Next Right Steps, LLC
2625 Piedmont Road NE
Suite 56-496
Atlanta, GA 30324
Does client have peer relationships?
If yes, please describe:
Yes
No
Does client get along with peers at school/work/church?
Yes
No
How does client relate to adults/persons of authority? Please describe:
Please provide any additional information and/or insight that you think may be
helpful:
11
