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TRAIL Participant Intake
General Information
Parent(s) Name(s):
*
Child(ren) Name(s):
*
DOB:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
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10
11
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18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
E-mail:
*
Phone:
*
Address:
*
City:
*
State:
*
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code:
*
Country:
Option 1
Option 2
Option 3
Developmental History:
Compared to other children, does/did your child have difficulty with:
Talking
Understanding
Gross Motor Skills
Fine Motor Skills
Early School Skills
Sitting Still
Playing/Socializing w/Others
Toilet Training
Explain:
Medical History:
If yes please explain at bottom:
Seizures
Serious Illness
Operations
Allergies
Head Injury
Abdominal Pains/Vomiting
Headaches
Ear Infections
Visual Problems
Currently on Medication(please list below)
Hyper/Hypo active
Demands Attention
Does Not Eat Well
Shy/Timid
Speech Difficulty
Mood Changes
Tantrums
Aggression
Depressed
Non-Verbal
Repeats Certains Acts Over and Over
Wanders Away
Cries Often
Explain:
Educational History:
Name of School:
School Address:
Contact Person at School:
Additional Educational Information:
Repeated a Grade
Attended Early Education
Passed Kindergarten Screening
Any Other Information You Would Like to Tell Us:
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