If you are interested in initiating FirstSteps' services, please submit this application form, or simply contact our clinic at 310.374.3300. We look forward to hearing from you.

Your Child

Child's Name: Date of Birth:

Contact Information

Mother's Name: Father's Name: Home Address: Home Phone: Daytime Phone: Mobile Phone: Email Address:  

Diagnostic Information

Has your child previously been evaluated or been given a diagnosis? Are you seeking confirmation or evaluation of the diagnosis? Current Diagnosis: Diagnosis Date: Diagnosed By: How did you find out about us?  

Background Information

When did you first become concerned about your child's development? Did your child meet all first year milestones at age appropriate times? Did you have any concerns during your child's second year? Please briefly explain your child's language and communcation Please briefly explain your child's social behavior Do you have any concerns regarding your child's behavior, such as tantrums or repetitive behaviors? Did your child experience a regression, or loss of skills? If so, how and when?  

School & Treatment History

Name of school: Grade: Special education placement: Are you pleased with the current school placement? Has your child received any specialized services to date? ABA Speech OT Other Other  

Your Child

What are your child's strengths? What are your child's areas of need?  

Family Goals

Services of interest: Immediate family goals: Long term family goals: