Child Information

Child's Full Name: *

Child's Date of Birth: *

Child's Age: *

Child's Gender *

Primary Language Spoken at Home: *

School and Grade Level: *

Does your child attend childcare or preschool (if applicable)?

Yes

Parent/Guardian Information

Name(s): *

Relationship to Child: *

Phone *

Email *

Preferred Method of Contact: *

Phone

Text

Reason for Referral *

Behavioral Concerns (e.g., tantrums, aggression, difficulty following directions, emotional regulation) Details:

Academic Concerns (e.g., reading difficulties, attention issues, trouble completing homework) Details:

Developmental Concerns (e.g., speech/language delays, motor skills, social interaction) Details:

Please describe your concerns in the following areas (check all that apply and provide details where relevant):

What do you see as your child’s strengths or things they enjoy? *

Developmental History

Was your child born full term? *

Yes

If no - please explain:

Were there any complications during pregnancy, birth, or shortly after? *

Yes

If yes - please explain:

Has your child reached developmental milestones on time (e.g., walking, talking)? *

Yes

If no- please explain

Is your child currently receiving any of the following services? (Check all that apply) *

Speech Therapy

Occupational Therapy

Physical Therapy

Counseling/Therapy

Special Education Services (IEP or 504 Plan)

Other

If other - please explain

Is there anything else you’d like us to know about your child or family?

Who is your child's pediatrician? *

How did you hear about Building All Children®? *

Once you submit this form, you will be contacted personally by a Building All Children

team member.