Pediatric Client Intake Form (Page 4 of 4) in pdf

Personal History

Please describe your child’s communication style:

 Verbal

 Word Approximations

 ASL

 PECs

 Augmentative Device

 Gestures None

Other: __________________________________________________________________________________

How does your child deal with change? _______________________________________________________

_______________________________________________________________________________________

What types of methods does your child use to manage stressful situations (self-soothing techniques)?

_______________________________________________________________________________________

What makes your child:

(And, how do you deal with it)

Happy?

Sad?

Angry?

Stressed?

Excited?

 Yes  No

Does your child attend school/preschool/daycare?

If yes, what are his/her teacher’s name(s)? ____________________________________________________

What are the names/types of his/her pets? ____________________________________________________

What are the names of his/her siblings? _______________________________________________________

What are the names of his/her friends? ________________________________________________________

What types of exercise interests your child? ___________________________________________________

How does your child prefer to spend his/her time (hobbies/interests)? ________________________________

________________________________________________________________________________________

I have listed all my child’s known medical conditions and physical limitations and will inform the massage

therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must

be aware of any and all existing physical conditions that I have in order to provide appropriate massage. I

further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other

medical, physical, or emotional disorder, nor performs any thrusting joint or spinal manipulations or

adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my

child may have.

I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being charged.

Signed ________________________________________________ Date ____________________

Parent/Legal Guardian of ___________________________________________________________

Page 4 of 4 Child’s Name: _______________________

Pediatric Client Intake Form Page 4