Assessment and Therapy Associates of Grand Forks, PLLC
725 Hamline Street
Grand Forks, North Dakota 58203
(701) 780-6821 (phone) (701) 780-1973 (fax)
PEDIATRIC BACKGROUND INFORMATION FORM
Last Name: Age: Child‟s First Name: Date of Birth:
Name of Parent(s)/Guardian: (mother): (father):
Name of Person Completing This Form: Relationship to Child:
Do you have legal custody of this child? Yes No
City: State: Zip: Address: Street:
Phone: Home: ( ) - Work: ( ) - Cell/Other: ( ) -
May we leave messages at: Home? Yes No Work? Yes No Cell? Yes No
E-mail Address (if you would like to use this for communication):
How were you referred to this clinic?
Who is your child‟s primary care physician/provider?
Would you like a copy of this evaluation sent to your child‟s physician/provider? Yes No
If yes, where does this provider practice (i.e., name/address of clinic):
(Please give your insurance card to the office manager)
Person responsible for bill: Date of Birth: Relationship to patient:
Home phone no.: ( ) - Address of responsible party (if different):
Is this patient covered by insurance? Yes No Name of Insurance Company/Plan:
Subscriber‟s name: Plan Number/ID: Group Number:
Patient‟s relationship to subscriber: Self Child Other Subscriber‟s Date of Birth:
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the clinician. I understand that I am financially responsible for any balance. I also authorize Assessment and Therapy Associates of Grand Forks,
PLLC or insurance company to release any information required to process my claims (please initial):
Please describe the problems that your child is demonstrating:
How long have these problems been present?
Are these problems related to any specific event or situation? Yes No
If yes, describe the event/situation:
Is your child currently in therapy for these problems? Yes No If yes, who is the therapist? Does your child currently take medication(s) for this or any other emotional or behavioral problem? Yes No If yes, what medication(s) does he/she take? Who manages this medication?
If your child is being seen for an assessment, what questions would you like to have answered?
Has your child had therapy previously? Yes No If yes, who was therapist? What problems did previous therapy address?
Has your child previously taken any medication(s) for this or any other emotional or behavioral problem? Yes No If yes, what medication(s) did he/she take? Who managed this medication?
Has your child ever been evaluated for learning, developmental, emotional, or behavioral issues? Yes No If yes, what types of evaluation(s) has your child had (CHECK AND DESCRIBE ALL THAT APPLY):
Emotional/Behavioral Problems Who conducted evaluation?
Cognitive/Learning Evaluation Who conducted evaluation?
Developmental Delays Who conducted evaluation?
Speech/Language Problems Who conducted evaluation?
Fine or Gross Motor Who conducted evaluation?
Sensory Integration Who conducted evaluation?
Visual Processing Evaluation Who conducted evaluation?