Loading...
Case History Form2020-06-16T13:39:14+00:00

Case History Form

  • Date Format: MM slash DD slash YYYY



  • SIBLING INFORMATION


  • BIRTH HISTORY


  • MEDICAL HISTORY

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • OTHER PROFESSIONALS WORKING WITH YOUR CHILD


  • MOTOR DEVELOPMENT (note age of)


  • FEEDING DEVELOPMENT (note age of)


  • SPEECH AND LANGUAGE DEVELOPMENT (note age of)


  • PSYCHOLOGICAL AND NEUROLOGICAL DEVELOPMENT


  • EDUCATIONAL DEVELOPMENT


  • INSURANCE INFORMATION

    In order to submit claims for insurance reimbursement, we will need the following information:

  • Date Format: MM slash DD slash YYYY

  • FINAL INFORMATION

    It may be helpful to keep a 2 day log of foods your child eats and bring this information to your first appointment.

  • Please Review the 3 documents listed below.

  • Please Review Miracle Farm Speech Therapy's Terms of Agreement

  • Please Review Miracle Farm Speech Therapy's Informed Consent and Treatment Form

  • Please Review Miracle Farm Speech Therapy's Covid-19 Liability Release