Contact Us 3905 University Drive Durham, NC 27707 Phone: 919.928.0204 Fax: 919.928.9423 Send Us a Message Date Child's NameDate of Birth* SexAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Phone*Who referred child to Emerge:Phone Number*AddressReason for Referral:FAMILY INFORMATION:Parent's NameBirthdate* OccupationCell PhonePlace of EmploymentBusiness PhoneEmail Address* Parent's NameBirthdate* OccupationCell PhonePlace of EmploymentBusiness PhoneEmail Address With whom does child live?Biological Parent(s)Adoptive ParentsAdopted at Age:Other (Specify)Health Insurance company List all other persons living in home:Name / Age / Relationship to childBIRTH INFORMATION:Any difficulties during pregnancy or delivery (Specify)Length of PregnancyLength of LaborBirth WeightAny problems in newborn period (Specify)SCHOOL HISTORY:Please provide location and dates.Preschool or daycareKindergartenElementary SchoolPresent gradeSchoolTeacherPhoneIs your child in a special class or receiving any support services?Please list allDEVELOPMENTAL MILESTONES:Specify the age at which your child (leave blank if not applicable or you don’t remember):Sat without supportCrept on hands & kneesWalked independentlyJumpedRode a tricyleDressed independentlyNamed simple objectsRode a bicycle(no training wheels)Used single words(e.g., no, mom, dog)Combined words(e.g. me go, daddy)Used simple questions(e.g. Where's cup?)Engaged in conversationDrew a recognizable pictureCut out a shape with scissorsDo or did you have any concerns about your child's achievement of early developmental milestones?YesNoIf yes, please describe:PROFESSIONAL AND MEDICAL CONTACTS:Please list any of the following with whom you have had contact concerning your child. If any of these professionals have tested your child, please include a copy of the report.PediatricianName/Address/PhonePsychologistName/Address/PhoneTutorName/Address/PhoneOccupational TherapistName/Address/PhonePhysical TherapistName/Address/PhoneSpeech TherapistName/Address/PhoneNeurologistName/Address/PhoneOther (specify)Name/Address/PhoneList any medications that your child is currently taking:List any allergies your child has (including food):Has your child had any surgeries? If yes, what type and when (e.g. tonsillectomy, tube placement, etc.)?Has your child’s hearing been tested (when and results):Has your child‘s vision been tested (when and results):ACTIVITY HISTORY :Please provide any past or current activities along with your child's reaction to the experience. GymnasticsMusic Class/lessonsDance or movement classKarate or Tae Kwon DoScoutingOrganized sportsOtherWhat does your child enjoy playing with? How does your child entertain him/herself?What are your concerns about your child?What have you been told by doctors, teachers and/or others about your child?Please include any diagnoses you have been given.What do you see as your child's strengths?Please describe a typical day for your child, particularly if you have any behavioral concerns.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.