Pacific Therapy Services 5550 Telegraph Rd Ste A Ventura-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the child's name and age in the designated fields at the top of the form.
3. Indicate who has custody of the child by selecting from options such as Mother, Father, Both, Relative, or Other.
4. Fill out the child's school history, including current school district, grade, school name, and contact information for their teacher or counselor.
5. Review and document any special education status and classroom settings applicable to your child.
6. Detail any interventions that have been used to address problems in school.
7. Describe any symptoms or behaviors affecting your child by checking relevant boxes and providing additional details as needed.
8. Complete sections regarding significant family events, family health history, substance abuse history, and developmental milestones.
9. Finally, ensure you sign and date the form at the bottom before submitting it for processing.

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