| Child’s Name | Today’s Date | ||||||||
| Birthday | Age | Gender: □ Male □ Female | ||||||||
| Home address | |
| School | Teacher(s) | ||||||
| Person(s) filling out this form: □ Mother □ Father □ Stepmother □ Stepfather □ Caregiver | |
| □ Other (please explain) | |
| Mother’s Name | Age | Education | |||||||||||
| Occupation | Phone: Home | Business: | |||||||||||
| Father’s Name | Age | Education | |||||||||||
| Occupation | Phone: Home | Business: | |||||||||||
| Stepmother’s Name | Age | Education | |||||||||||
| Occupation | Phone: Home | Business: | |||||||||||
| Stepfather’s Name | Age | Education | |||||||||||
| Occupation | Phone: Home | Business: | |||||||||||
| Marital status of parents | If separated or divorced, how old was the child when the separation/divorce occurred? | ||||||||||||
| If remarried, how old was the child when the stepparent entered the family? | |||||||||||||
| Please list all people living in the household (please list additional people on a separate sheet of paper if necessary): | |||||||||||||
| Name | Gender | Relationship to Child | Age |
| Please list all other significant people living outside the home (please list additional people on a separate sheet of paper if necessary): | |||||||||||||
| Name | Gender | Relationship to Child | Age |
| Dominant language spoken in the home | Other language(s) spoken in the home | ||||||||||||
| What language does the child use to speak to you? | |||||||||||||
| What language does the child use to speak with friends? | |||||||||||||
| Was the child adopted? □ Yes □ No | If yes, at what age? | Does the child know? □ Yes □ No | |||||||||||
| Name of current medical provider(s): | |||||||||||||
Presenting Problem
| |||||||||||||
| Briefly describe the child’s current difficulties: | |||||||||||||
| How long has this problem been of concern to you? | |||||||||||||
| When was the problem first noticed? | |||||||||||||
| What seems to help the problem? | |||||||||||||
| What seems to make the problem worse? | |||||||||||||
| Have you noticed any changes in the child’s abilities? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Have you noticed any changes in the child’s behavior? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Has the child received an evaluation or treatment for the current problem or similar problems? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Is the child being treated for a medical illness? □ Yes □ No | |||||||||||||
| If yes, for what condition is the child being treated? | |||||||||||||
| Is the child on any medication at this time? □ Yes □ No | |||||||||||||
| If yes, please note the kind of medication and what it is being taken for: | |||||||||||||
| So | |||||||||||||
| □ | Has difficulty with hearing | ||||||||||||
| □ | Has difficulty with vision | ||||||||||||
| □ | Has difficulty with coordination | ||||||||||||
| □ | Has difficulty with balance | ||||||||||||
| □ | Has difficulty making friends | ||||||||||||
| □ | Has difficulty keeping friends | ||||||||||||
| □ | Refuses to share | ||||||||||||
| □ | Prefers to be alone | ||||||||||||
| □ | Does not get along well with siblings | ||||||||||||
| □ | Does not get along well with adults | ||||||||||||
| □ | Fights verbally with adults | ||||||||||||
| □ | Fights physically with adults | ||||||||||||
| □ | Yells and calls children names | ||||||||||||
| □ | Shows wide mood swings | ||||||||||||
| □ | Is aggressive (describe) | ||||||||||||
| □ | Is withdrawn (describe) | ||||||||||||
| □ | Is shy or timid | ||||||||||||
| □ | Clings to others | ||||||||||||
| □ | Is more interested in things (objects) than in people | ||||||||||||
| □ | Engages in behavior that could be dangerous to self or others (describe) | ||||||||||||
| □ | Breaks objects deliberately | ||||||||||||
| □ | Lies (describe) | ||||||||||||
| □ | Steals (describe) | ||||||||||||
| □ | Injures self often | ||||||||||||
| □ | Runs away | ||||||||||||
| □ | Has low self-esteem | ||||||||||||
| □ | Blames others for his/her troubles | ||||||||||||
| □ | Is argumentative | ||||||||||||
| □ | Does not get along well with other children | ||||||||||||
| □ | Fights verbally with other children | ||||||||||||
| □ | Fights physically with other children | ||||||||||||
| □ | Does not show feelings | ||||||||||||
| □ | Has frequent crying spells | ||||||||||||
| □ | Has unusual or special fears, habits, or mannerisms (describe) | ||||||||||||
| □ | Wets bed | ||||||||||||
| □ | Bites nails | ||||||||||||
| □ | Sucks thumb | ||||||||||||
| □ | Has frequent temper tantrums | ||||||||||||
| □ | Has trouble sleeping (describe) | ||||||||||||
| □ | Rocks back and forth | ||||||||||||
| □ | Bangs head | ||||||||||||
| □ | Holds breath | ||||||||||||
| □ | Eats poorly | ||||||||||||
| □ | Is stubborn | ||||||||||||
| □ | Has poor bowel control (soils self) | ||||||||||||
| □ | Is much too active | ||||||||||||
| □ | Is fidgety | ||||||||||||
| □ | Is easily distracted | ||||||||||||
| □ | Is disorganized | ||||||||||||
| □ | Is clumsy | ||||||||||||
| □ | Is unusually talkative | ||||||||||||
| □ | Is forgetful | ||||||||||||
| □ | Has blank spells | ||||||||||||
| □ | Daydreams too much | ||||||||||||
| □ | Worries a lot | ||||||||||||
| □ | Is impulsive | ||||||||||||
| □ | Takes unnecessary risks | ||||||||||||
| □ | Gets hurt frequently | ||||||||||||
| □ | Has too many accidents | ||||||||||||
| □ | Doesn’t learn from experience | ||||||||||||
| □ | Feels that he/she is bad | ||||||||||||
| □ | Is slow to learn | ||||||||||||
| □ | Moves slowly | ||||||||||||
| □ | Stares into space for long periods | ||||||||||||
| □ | Engages in stereotyped behavior (describe) | ||||||||||||
| □ | Does not understand other people’s feelings | ||||||||||||
| □ | Has difficulty following directions | ||||||||||||
| □ | Gives up easily | ||||||||||||
| □ | Complains of aches/pains | ||||||||||||
| □ | Is disobedient | ||||||||||||
| □ | Gets into trouble with the law | ||||||||||||
| □ | Constantly seeks attention | ||||||||||||
| □ | Is restless | ||||||||||||
| □ | Has periods of confusion or disorientation | ||||||||||||
| □ | Is jealous (describe) | ||||||||||||
| □ | Is extremely selfish | ||||||||||||
| □ | Feels hopeless | ||||||||||||
| □ | Is nervous or anxious | ||||||||||||
| □ | Is immature | ||||||||||||
| □ | Is easily frustrated | ||||||||||||
| □ | Has difficulty learning when there are distractors | ||||||||||||
| □ | Is suspicious of other people | ||||||||||||
| □ | Requires constant supervision | ||||||||||||
| □ | Has difficulty resisting peer pressure | ||||||||||||
| □ | Shows anger easily | ||||||||||||
| □ | Has difficulty accepting criticism | ||||||||||||
| □ | Feels sad or unhappy often | ||||||||||||
| □ | Talks about wanting to die | ||||||||||||
| □ | Has poor attention span | ||||||||||||
| □ | Has poor memory | ||||||||||||
| □ | Sets fires | ||||||||||||
| □ | Is afraid of new situations | ||||||||||||
| □ | Has trouble making plans | ||||||||||||
| □ | Eats inedible objects | ||||||||||||
| □ | Is not toilet trained | ||||||||||||
| □ | Uses illegal drugs (describe) | ||||||||||||
| □ | Drinks alcohol | ||||||||||||
| □ | Other problems (describe) | ||||||||||||
| Please place a check next to any behavior problem that the child has shown within the last three months. | |||||||||||||
| □ | Shows sexually provocative behavior | ||||||||||||
| □ | Has extreme fear of bathroom or bathing | ||||||||||||
| □ | Has anxiety when separated from parents | ||||||||||||
| □ | Has extreme anxiety about going to school | ||||||||||||
| □ | Has fear at bedtime | ||||||||||||
| □ | Is wary of any physical contact with adults in general | ||||||||||||
| □ | Refuses to sleep alone | ||||||||||||
| □ | Refuses to go to bed | ||||||||||||
| □ | Has loss of bladder control | ||||||||||||
| □ | Is fearful of strangers | ||||||||||||
| □ | (In cases of divorce) Is fearful of visiting a parent or caregiver | ||||||||||||
| □ | Overeats | ||||||||||||
| □ | Is very eager to please others | ||||||||||||
| □ | Refuses to undress for physical education classes at school | ||||||||||||
| □ | Has compulsion about cleanliness—wanting to wash or feeling dirty all the time | ||||||||||||
| □ | Appears dazed, drugged, or groggy upon return from visiting a divorced or separated parent | ||||||||||||
| □ | Other recent behaviors or problems (describe) | ||||||||||||
Language/Speech Checklist
| |||||||||||||
| Please place a check next to any language problem that the child currently exhibits. | |||||||||||||
| □ | Speaks in shorter sentences than expected for age | ||||||||||||
| □ | Does not know names of common objects | ||||||||||||
| □ | Has difficulty recalling familiar words | ||||||||||||
| □ | Substitutes vague words (e.g., “thing”) for specific words | ||||||||||||
| □ | Responds better to gestures than to words | ||||||||||||
| □ | Does not make appropriate gestures to communicate | ||||||||||||
| □ | Uses gestures instead of words to express ideas | ||||||||||||
| □ | Has difficulty making speech understood | ||||||||||||
| □ | Speaks very slowly | ||||||||||||
| □ | Speaks too fast | ||||||||||||
| □ | Is often hoarse | ||||||||||||
| □ | Has unusually loud speech | ||||||||||||
| □ | Has unusually soft speech | ||||||||||||
| □ | Makes sounds but no words | ||||||||||||
| □ | Mixes up the order of events | ||||||||||||
| □ | Seems uninterested in communicating | ||||||||||||
| □ | Prefers to speak to adults only | ||||||||||||
| □ | Prefers to speak to children only | ||||||||||||
| □ | Prefers to speak to family members only | ||||||||||||
| □ | Speaks in a monotone or exaggerated manner | ||||||||||||
Educational Checklist
| |||||||||||||
| Please place a check next to any educational problem that the child currently exhibits. | |||||||||||||
| □ | Has difficulty with reading | ||||||||||||
| □ | Has difficulty with math | ||||||||||||
| □ | Has difficulty with spelling | ||||||||||||
| □ | Has difficulty with handwriting | ||||||||||||
| □ | Has difficulty with other subjects (describe) | ||||||||||||
| □ | Has difficulty paying attention in class | ||||||||||||
| □ | Has difficulty sitting still in class | ||||||||||||
| □ | Has difficulty waiting turn in school | ||||||||||||
| □ | Has difficulty taking notes in class | ||||||||||||
| □ | Has difficulty respecting others’ rights | ||||||||||||
| □ | Has difficulty remembering things | ||||||||||||
| □ | Forgets homework | ||||||||||||
| □ | Has difficulty getting along with teacher | ||||||||||||
| □ | Has difficulty getting along with other children | ||||||||||||
| □ | Dislikes school | ||||||||||||
| □ | Resists going to school | ||||||||||||
| □ | Refuses to do homework | ||||||||||||
| Did the child attend preschool? □ Yes □ No | |||||||||||||
| If yes, at what age(s)? | How often? | ||||||||||||
| At what age did the child begin kindergarten? | What is his/her current grade? | ||||||||||||
| How many schools has the child attended? | Names of schools: | ||||||||||||
| Has the child ever been in special education? □ Yes □ No | |||||||||||||
| If yes, what type of class/services? | |||||||||||||
| Is the child currently in special education? □ Yes □ No | |||||||||||||
| If yes, what type of class/services? | |||||||||||||
| Has the child ever been held back in a grade? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Has the child ever received special tutoring or therapy in school? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Has the child’s performance become poorer recently? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Has the child missed a lot of school? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
Developmental History
| |||||||||||||
| Pregnancy | |||||||||||||
| Did the mother have any problem during the pregnancy? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, what kind? | |||||||||||||
| How old was the mother when she became pregnant? | Was this a first pregnancy? □ Yes □ No | ||||||||||||
| If no, how many times was the mother previously pregnant? | |||||||||||||
| During the pregnancy, did the mother smoke? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, how many cigarettes each day? | |||||||||||||
| During the pregnancy, did the mother drink alcoholic beverages? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, what did she drink? | Approximately how much alcohol was consumed each day? | ||||||||||||
| During which part of the pregnancy—1st trimester, 2nd trimester, 3rd trimester—was the alcohol consumed? | |||||||||||||
| Were there times when 5 or more drinks were consumed? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, during which trimester—1st trimester, 2nd trimester, 3rd trimester? | |||||||||||||
| During the pregnancy, did the mother use drugs (including prescription, over-the-counter, and recreational)? □ Yes □ No □ Don’t Know If yes, what kind? | |||||||||||||
| During the pregnancy, was the mother exposed to any x-rays or chemicals? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, what kind? | |||||||||||||
| During the pregnancy, was the mother exposed to any infectious diseases? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, what kind? | |||||||||||||
| During the pregnancy, did the mother receive prenatal care? □ Yes □ No □ Don’t Know | |||||||||||||
| Was de livery induced? □ Yes □ No □ Don’t Know | |||||||||||||
| How long was labor? | Were forceps used during delivery? □ Yes □ No □ Don’t Know | ||||||||||||
| Was a cesarean section performed? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, for what reason? | |||||||||||||
| Were there any complications associated with the delivery? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, what kind? | |||||||||||||
| Was the child premature? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, by how many weeks? | |||||||||||||
| Was neonatal care needed? □ Yes □ No □ Don’t Know | |||||||||||||
| If yes, what kind of care and how long was it needed? | |||||||||||||
| Infancy | |||||||||||||
| What was the child’s birth weight? | Were there any birth defects or complications? □ Yes □ No | ||||||||||||
| If yes, please describe: | |||||||||||||
| Were there any feeding problems? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Were there any sleeping problems? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Were there any other problems? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| As an infant, was the child quiet? □ Yes □ No | As an infant, did the child like to be held? □ Yes □ No | ||||||||||||
| AS an infant, was the child alert? □ Yes □ No | As an infant, did the child grow normally? □ Yes □ No | ||||||||||||
| If no, please describe: | |||||||||||||
| As an infant, was the child different in any way from siblings? □ Yes □ No □ Not applicable | |||||||||||||
| If yes, please describe: | |||||||||||||
| First Years | |||||||||||||
| □ | Did no enjoy cuddling | ||||||||||||
| □ | Was not calmed by being held | ||||||||||||
| □ | Was colicky | ||||||||||||
| □ | Was excessively restless | ||||||||||||
| □ | Had poor sleep patterns | ||||||||||||
| □ | Banged head frequently | ||||||||||||
| □ | Was constantly into everything | ||||||||||||
| □ | Had an excessive number of accidents | ||||||||||||
| □ | Was exposed to lead | ||||||||||||
| □ | Had fine-motor problems | ||||||||||||
| □ | Had gross-motor problems | ||||||||||||
| □ | Did not babble | ||||||||||||
| □ | Did not speak | ||||||||||||
| □ | Had excessive fears | ||||||||||||
| □ | Ignored toys | ||||||||||||
| □ | Was attached to an unusual object (describe) | ||||||||||||
| □ | Was unaware of painful bumps or falls | ||||||||||||
| □ | Had peculiar patterns of speech | ||||||||||||
| □ | Preferred to play alone | ||||||||||||
| □ | Had poor eye contact | ||||||||||||
| □ | Was not interested in other children | ||||||||||||
| □ | Did not smile socially | ||||||||||||
| □ | Was insensitive to cold or pain | ||||||||||||
| □ | Did not wave bye-bye | ||||||||||||
| Were there any other special problems in the growth and development of the child during the first few years? □ Yes □ No If yes, please describe: | |||||||||||||
| The following is a list of infant and preschool behaviors. Please indicate the age at which the child first demonstrated each behavior. If you are not certain of the age but have some idea, write the age followed by a question mark. If you don’t remember or don’t know the age at which the behavior occurred, please write a question mark. If the child has not yet demonstrated the behavior, write an X. | |||||||||||||
| Behavior | Age | Behavior | Age | Behavior | Age |
| Showed response to mother | Babbled | Played pat-a-cake or peek-a-boo | |||
| Held head erect | Spoke first word | Took off clothing alone | |||
| Rolled over | Showed fear of strangers | Put on clothing alone | |||
| Sat alone | Put several words together | Tied shoelaces | |||
| Crawled | Became toilet trained (day) | Rode tricycle | |||
| Stood alone | Stayed dry at night | Named colors | |||
| Walked alone | Drank from cup | Said alphabet in order | |||
| Ran with good control | Fed self |
Child’s Medical History
| |||||||||||||
| Please place a check next to any illness or condition that the child has had. When you check an item, also note the approximate age of the child when he/she had the illness or condition. | |||||||||||||
| Illness or condition | Age | Illness or condition | Age | Illness or condition | Age | |||
| □ | Measles | □ | Seizures | □ | Bone or joint disease | |||
| □ | German measles | □ | Broken bones | □ | Gonorrhea or syphilis | |||
| □ | Mumps | □ | Hearing problems | □ | Anemia | |||
| □ | Chicken pox | □ | Ear infections | □ | Jaundice/hepatitis | |||
| □ | Whooping cough | □ | Seeing problems | □ | Diabetes | |||
| □ | Diphtheria | □ | Fainting spells | □ | Cancer |
| □ | Polio | □ | Loss of consciousness | (list type) |
| □ | Scarlet fever | □ | Paralysis | □ | High blood pressure | |||
| □ | Meningitis | □ | Dizziness | □ | Heart disease | |||
| □ | Encephalitis | □ | Frequent headaches | □ | Asthma | |||
| □ | High fever | □ | Difficulty concentrating | □ | Bleeding problems | |||
| □ | Convulsions | □ | Memory problems | □ | Eczema or hives | |||
| □ | Allergies | □ | Extreme tiredness | □ | Suicide attempt(s) |
| (please list) | □ | Rheumatic fever | □ | Sleeping problems |
| □ | Hay fever | □ | Epilepsy | □ | HIV | |||
| □ | Injuries to head | □ | Tuberculosis | □ | AIDS |
| Does the child have any disabilities? □ Yes □ No If yes, please describe: | |||||||||||||
| Has the child had any serious illnesses? □ Yes □ No If yes, what illnesses: | |||||||||||||
| Has the child been hospitalized? □ Yes □ No If yes, please list reason(s): | |||||||||||||
| Has the child had any operations? □ Yes □ No If yes, please list reason(s): | |||||||||||||
| Has the child had any accidents? □ Yes □ No If yes, please describe: | |||||||||||||
| Are the child’s immunizations up to date? □ Yes □ No Child’s height | Child’s weight | ||||||||||||
Family Medical History
| |||||||||||||
| Please place a check next to any illness or condition that any member of the immediate family has had. When you check an item, please note the family member’s relationship to the child. | |||||||||||||
| Relationship to child | Relationship to child | ||||
| □ | Academic problem | □ | Emotional Problem | ||
| □ | Alcoholism | □ | Epilepsy | ||
| □ | Cancer | □ | Heart trouble | ||
| □ | Depression | □ | Neurological disease | ||
| □ | Developmental problem | □ | Suicide attempt | ||
| □ | Diabetes | □ | Other problems (please list) |
| □ | Drug problem |
Other Information
| |||||||||||||
| Child’s Activities | |||||||||||||
| What are the child’s favorite activities? | |||||||||||||
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| What activities would the child like to engage in more often than he/she does at present? | |||||||||||||
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| What activities does the child like least? | |||||||||||||
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| What chores does the child do around the house? | |||||||||||||
| Has there been any recent change in his/her ability to carry out these chores? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| What time does the child usually go to bed on weekdays? | On weekends? | ||||||||||||
| Has the child ever been in trouble with the law? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| Has the child ever been referred to Child Protective Services or another similar agency? □ Yes □ No | |||||||||||||
| If yes, please describe: | |||||||||||||
| □ | Sets table | □ | Helps with grocery shopping | □ | Puts clothes away |
| □ | Cooks meals | □ | Unpacks groceries | □ | Sews |
| □ | Cleans table | □ | Does laundry | □ | Empties garbage |
| □ | Washes dishes | □ | Does ironing | □ | Does homework alone |
| □ | Cleans room | □ | Other (please list) |
| Child’s Responsibilities | |||||||||||||
| Can the child be trusted to care for a pet? □ Yes □ No | |||||||||||||
| If no, why not? | |||||||||||||
| Does the child handle his/her personal finances? □ Yes □ No | |||||||||||||
| If no, why not? | |||||||||||||
| Does the child take responsibility for his/her personal hygiene? □ Yes □ No | |||||||||||||
| If no, why not? |
| Is the child’s behavior generally age appropriate? □ Yes □ No | |||||||||||||
| If no, please describe in what ways it is not age appropriate: | |||||||||||||
| Other Areas | |||||||||||||
| What do you enjoy doing with your child? | |||||||||||||
| What have you found to be the most satisfactory ways to help the child? | |||||||||||||
| What are the child’s strengths? | |||||||||||||
| Is there any other information you think may help us in working with the child? | |||||||||||||
| Family Stress Survey | |||||||||||||
| Every family sometimes experiences some form of stress. Please put a check next to each event that your family has experienced in the last 12 months. | |||||||||||||
| □ | Child’s mother died | ||||||||||||
| □ | Child’s father died | ||||||||||||
| □ | Child’s brother died | ||||||||||||
| □ | Child’s sister died | ||||||||||||
| □ | Parents divorced | ||||||||||||
| □ | Parents separated | ||||||||||||
| □ | Grandparent died | ||||||||||||
| □ | Someone in family was seriously injured or became ill (list person): | ||||||||||||
| □ | Parent remarried | ||||||||||||
| □ | Father lost job | ||||||||||||
| □ | Mother lost job | ||||||||||||
| □ | Family moved to another city | ||||||||||||
| □ | Family moved to another part of town | ||||||||||||
| □ | Someone in the family was in trouble with the law (list person): | ||||||||||||
| □ | Family’s financial condition changed | ||||||||||||
| □ | Member of family was accused of child abuse or neglect (list person): | ||||||||||||
| □ | Neighborhood was changing for the worse | ||||||||||||
| □ | Child was a victim of violence | ||||||||||||
| □ | Family experienced a natural disaster (list): | ||||||||||||
| □ | Child started having trouble with parent(s) (caregiver) | ||||||||||||
| □ | Child started having trouble with sibling(s) | ||||||||||||
| □ | Child started having trouble in school | ||||||||||||
| □ | Child changed schools | ||||||||||||
| □ | Child’s close friend moved away | ||||||||||||
| □ | Child’s pet died | ||||||||||||
| □ | Other types of stress (list): | ||||||||||||