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About Us
Services
- Teletherapy
- Schools
Insurances
Registration

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786-693-1660

Registration Forms

CHILD DEMOGRAPHICS:

Name of Child:

Gender

DOB

Age

Today's Date

Current Address

.FL

Parents and/or Guardians:

(Attach a copy of Driver License)

Best Number to Reach:

E-mail

Emergency Contact Name (not living with you)

Relationship to child:

Current Diagnosis:

Referring Physician:

Current Address

.FL

Phone Number:

EDUCATIONAL HISTORY

Name of School Center:

Principal/Contact Person:

Teacher’s Name:

Phone Number:

Fax Number:

E-mail:

Address:

MEDICAL HISTORY

1)- Please indicate at what age each major milestone was reached (N/A not applicable):

Rolled Over consistently:

Sat up unsupported:

Stood:

Crawled:

Walked Unassisted

Said 1st Word Intelligible to strangers:

Said two-three word phrases:

Used Sentences regularly:

Toilet trained during the day:

Dressed Self:

Dry through the night (6+ months) :

2)- Was child premature?

3)- Born at how many weeks gestation?

4)- Was child premature? Did your child require any medical procedures before, during, or after birth? Please describe:

5)-Please check if your child has had any of the following disorders (and if so, at what age):

Seizures Mumps Diphtheria Tonsillitis Rheumatic fever Respiratory disorders Asthma High fevers Chicken pox Head injury Meningitis Tuberculosis Enlarged glands Heart trouble Measles Whooping cough Pneumonia Encephalitis Sinusitis Thyroid Diabetes

What age?

6)- Please indicate if your child is experiencing any of the following disorder:

Problems with eating Isolated socially from peers Problems making friends Problems keeping friends Problems getting to sleep Problems controlling temper Problems sleeping through the night Fatigue/tiredness during the day Trouble waking up Nightmares Bed wetting Problems with authority Anxiety Unmotivated Stress from conflict between parents History of abuse Alcohol/drug use/abuse Sadness or Depression School concentration difficulties Grades dropping or consistently low

7)- List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child has had.

8)- Child’s current:

Height:

Weight:

9)- With which hand does the child write?

10)- Does the individual have any vision problems?

11)- Does the child have any hearing problems?

12)- Please list any medical diagnosis present for the child:

Autism/PDD Cerebral Palsy Physical/Speech Delay Learning Delay Attention-Deficit/Hyperactivity Disorder Vision/Hearing impairments Other

13)-Please list any current allergies that your child may have:

MEDICATIONS

Please list any medications that your child is currently taking:

INSURANCE/PAYMENT INFORMATION

Insurance Carrier:

Policyholder Name:

Plan/Program Name:

ID Number:

SMS Consent

By submitting this form you agree to receive SMS messages from Sien Therapy regarding our services.

By submitting this form you agree to receive SMS messages from Sien Therapy regarding our services.

We are Sien Therapy

With a commitment to excellence, we deliver top-notch care through teletherapy and school-based programs, ensuring every child receives the support they need to thrive in communication and beyond.

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Contact Information

info@sientherapy.com
786-693-1660

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