Getting in Touch: Next Steps

GETTING IN TOUCH:

The Next Steps
Date

MonthDayYear
Child's Name
Age
Date of Birth
Grade
School
Usual Dismissal Time
Early Dismissal (Day/Time)
Availability - List all possible time blocks for weekly tele-therapy sessions:
1. Monday
2. Tuesday
3. Wednesday
Current and/or Ongoing Issues (please prioritize and be very specific):
1.
2.
3.
4.
Clinical Diagnoses (Current and/or Past, e.g. OCD, Generalized Anxiety, Social Anxiety, Phobia, ADHD, Autism, etc.):
1.
2.
3.
Medical and/or Educational Diagnoses:
1.
2.
Your Child's Team (current and past) clinicians, therapists, pediatrician, etc.:
1.
2.
3.
Parent Name
Email
Cell
Parent Name
Email
Cell
Please add any additional, relevant information here:

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GETTING IN TOUCH: