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Our Team
Our Team
Dr Caleb Moore
Dr Sandra Lithgow
Dr Sara B Seidelmann
Dr Catherine Joyce
Dr Herbert Archer
Rebecca Stiritz PSY.D
About us
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Membership Inquiries
Medical Records
Patient Portal
Record Release
(203) 661-2596
(203) 625-8331
644 West Putnam Avenue Suite 203
Mon-Fri: 8:00 - 5:00
(203) 661-2596
(203) 625-8331
644 West Putnam Avenue Suite 203
Mon-Fri: 8:00 - 5:00
HOME
Our Team
Our Team
Dr Caleb Moore
Dr Sandra Lithgow
Dr Sara B Seidelmann
Dr Catherine Joyce
Dr Herbert Archer
Rebecca Stiritz PSY.D
About us
Membership Inquiries
Membership Inquiries
Medical Records
Patient Portal
Record Release
Child Intake Form
Home
Our Team
Rebecca Stiritz PSY.D
Child Intake Form
Child Information
Form
Referred By
Name of Child
Date Of Birth
Sex
Address
City
State
Zip Code
Home Phone
School & Current Grade
Pediatrician
Mother's Name
Address
Phone
Cell
Work
Occupation
Father's Name
Address
Phone
Cell
Work
Occupation
Parent's Marital Status
Patient's Siblings
Please list the names, ages, and dates-of-birth of the patient’s siblings
Payment Options
Mastercard
Visa
Amex
Check
Cash
Card Number
Exp Date
Sec Code
Reason for Referral
Other Concerns
Prenatal History
Were there any complications during pregnancy and/or delivery?
How old were you when your child was born?
Were any of the following taken during pregnancy? (select all that apply)
beer
wine
alcohol
coffee/caffeine
prescription medications
herbal products
Child’s birth weight? Apgar score?
Any health complications following birth?
Infancy
Were there any feeding, sleeping, responsiveness (alertness), or health problems during infancy?
How active was your child as an infant?
Developmental Milestones
Age He/She Sat Up
Age He/She Crawled
Age He/She Walked
Age Word Spoke (other than mama/dada)
Age Strung Words Spoke Together
Age Toilet Trained
Medical History
Please check and describe any problems with the following:
Hearing
Vision
Gross Motor Coordination
Fine Motor Coordination
Speech, Articulation, Language processing
Has your child had any chronic health problems?
Has your child had any of the following:
head injury
convulsions
coma
persistent high fevers
Is there any history of physical, sexual, or emotional abuse?
Does your child have difficulty sleeping at night?
Does your child have any difficulties with eating or with his/her appetite?
Educational And Learning Concerns
How is your child performing at school currently with regard to reading, math, and other academic skills?
At what grade level is your child functioning in reading and math?
Any difficulty completing assignments in school or at home?
Has your child ever had to repeat a grade?
Is he/she receiving any educational support services either in or outside of school?
Has your child’s teachers expressed concerns about him/her?
Please briefly describe your child’s experiences in:
Preschool
Grade School
Middle School
High School
Peer Relationships
How does your child get along with his/her siblings?
Does your child seek friendships with peers?
Do peers seek friendships with your child?
Briefly describe any concerns regarding peer-related problems
Psychiatric History
Has your child ever been evaluated by a mental health professional?
Has medication ever been prescribed for psychiatric, behavioral, attentional, or learning purposes?
Is there any family history of psychiatric, neurological, and/or learning disabilities in your extended family?
Other Concerns or Issues
Send
(203) 625-8331