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Introduce Us to Your Child

Children Names
Child Name Birth Date

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Favorite Play Materials
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Special Interests
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What opportunities does your child have to play with others the same age?
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Pets
Eating Patterns
Are there any dietary concerns?
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Does your child feed himself or herself?
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Are there any food dislikes?
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Are there any food allergies?
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When eating: (uses fingers, spoon, fork, cup, needs assistance)
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Sleeping Patterns
WHAT TIME IS:
Child Name Bedtime? Arise at? Nap time? How long?

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Does your child have a special toy/blanket to nap with?
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How is your child prepared for rest? (e.g. story time, quiet play, snack)
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Eliminating Patterns
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Child Name Potty trained (Y/N) In training (Y/N) How long?

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Does your child need to be reminded to go potty? How often?
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Does your child have a certain word to indicate a need to eliminate?
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Independent - Doesn't Require Help
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Child Wears
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Child Name Diaper (Y/N) Disposable training pants (Y/N) Cloth underwear (Y/N) Plastic pants over cloth underwear (Y/N)

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Stress/Coping Patterns
Does your child have any fears (e.g. storms, separation anxiety, dark, animals, stranger anxiety, being alone, other?)
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How do you soothe him or her?
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Activity Patterns
When Did Your Child Begin:
Child Name Creeping Crawling Walking

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Personality Traits
Please describe your child and list all that apply (e.g. shy, outgoing, curious, sensitive, frightens easily, verbal, cuddly, active, cautious, restless, stranger anxiety).
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Is there any other information we should know in order to help us know your child better?
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Other comments:
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Child Name	Birth Date

Child Name	Bedtime?	Arise at?	Nap time?	How long?

Child Name	Potty trained (Y/N)	In training (Y/N)	How long?

Child Name	Diaper (Y/N)	Disposable training pants (Y/N)	Cloth underwear (Y/N)	Plastic pants over cloth underwear (Y/N)

Complete and submit online

Introduce Us to Your Child

Eating Patterns

Sleeping Patterns

Eliminating Patterns

Child Wears

Stress/Coping Patterns

Activity Patterns

Personality Traits