Next Right Steps, LLC

2625 Piedmont Road NE

Suite 56-496
Atlanta, GA 30324

(770) 765-NEXT (6398)

www.nextrightsteps.com
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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
[email protected]

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