Intake - English

בס''ד
Registration (Intake)

Overview
Patient's Personal Information
Name:*
Last Name:*
ID
Telephone:*
Tel. at home:
Mail:
The completed form will be sent to this email address.
Date of birth:*

MonthDayYear
Date
תאריך

DayMonthYear
Date
Filling date:*

MonthDayYear
Date
גיל בימים
Age:
Adress:
Country:*
Place of study:
WHO:

KlalitMeuhedetMacabiLeumitNoneExtra Insurance/other:
Meuhedet supplementary insurance
Klalit supplementary insurance
Leumit supplementary insurance
Macabi supplementary insurance
Other, specify
No. of children in the family
His/her position in the family
Age of the eldest
Age of the youngest
No. of married siblings
Married Parents:

YesNo
About the father:*
About the mother:*
About the siblings:
How you heard about us:*
Background (How was it in the past)
What bothers you the most/you want to improve today
Development
Complicated childbirth

YesNo
Specify:
Delayed development

YesNo
Specify:
Age of first words:
First sentences:
Specify:
Received paramedical treatments such as: physiotherapy, hydrotherapy, occupational therapy/speech therapy, etc.

YesNo
Specify:
Medical problems in the past/present

YesNo
Specify:
Food sensitivities

MilkWhite sugarAny sugarFlourOther
Specify other:
Light/Sound/Touch Sensitivity:

ExcessiveLowNormal sensitivity
Bedwetting:

YesNoSometimes
Hours of sleep
How many nutritious meals a day
Specify:

[1-Not at all] [2-Little] [3-Yes] [4-A lot]

[1-None] [2-Little] [3-Enough] [4-A lot]*

	Medication	Dose	Beginning - Year	Month	End- Year	Month	Helps (1-4)	Spoils (1-4)	Comments (Side Effects and Effectiveness)
1.
2.
3.

[1-Above Average] [2-Average] [3-Slightly Below Average] [4-Well Below Average]

	Note	Specify:
Reading
Reading comprehension
Writing
Spelling
Lenguage
Gemara/Mishnah/Chumash
Mathematics
Crafts
Answer related to the question asked
Pays attention to teacher
Organization
Always busy while in class
Motivation

[1-Not at all] [2-A Little] [3-Yes] [4-A lot/Very]

	Note	Specify:
Issues with Friends/Teachers/Parents
Friends don't come home
Issues with body/nonverbal language
Freezes in social situations
Messy
Competitive
Unable to say no (limits)
Victim of bullying
Difficult Behavior

[1-Not at all] [2-Little] [3-Yes] [4-A lot/Very]

	Note	Specify
Shy
Perfectionist
Finds it difficult to postpone gratification
Hypersensitivity
Social anxiety
Anxiety about things, animals, etc.
Anxiety about the future
Non-Flexible Mind
Low self-esteem
Tendency to fear
Depressive
Explosive
Very active
Violent

Additional Notes:
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Treatment and supervision are by Hayeladim Shelanu organization's staff. Guaranteed Confidentiality - I ask the organization for assistance for my child and hereby give permission to transfer, if necessary, medical, paramedical, educational, and/or developmental material to therapists or authorized entities if necessary. I am aware that the treatment is not always effective for all persons and I agree not to sue and/or damage the rights of "Hayeladim Shelanu" or any person on its behalf for any reason:
Name*
Signature*

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Registration (Intake)