Académique Documents
Professionnel Documents
Culture Documents
Childs Name:
Date of Birth:
Age:
Home Address:
_________________________________________________________________________
Street Address
_________________________________________________________________________
City
State
Zip
Home Phone:
Work Phone: Mother:
Father:
Father:
E-Mail: Mother:
Father:
School:
System:
Grade:
Age:
Occupation:
Health:
Education Completed:
Excellent
Good
Fair
Poor
Fathers Name:
Age:
Occupation:
Health:
Education Completed:
Excellent
Good
Single
Married
Fair
Separated
Poor
Divorced
Widowed
Remarried
Is it full or joint?
Is it full or joint?
Father:
If yes, provide dates of other marriage(s), names, and ages of children from these marriages:
Mother:
Father:
Is there a birth parent living outside the home: (circle one) MOTHER FATHER
Where does this parent live?
If birth parent(s) do/does not live in the childs home, how much contact does the child have with the
parent(s) not having custody, with stepsiblings, etc.?
Unsatisfied
1
1
Somewhat Satisfied
2
2
Satisfied
3
3
Very Satisfied
4
4
Does either parents job require him/her to be away from home long hours or extended periods? If yes,
explain:
Siblings: List IN ORDER OF AGE siblings of child/adolescent for whom you are seeking services.
Name
Age
Grade
School
In general, how well does this child get along with his/her siblings?
Great
Describe:
Very Well
Good
Not Well
Very Poorly
Others: List any other people who currently, or in the childs lifetime, have lived in your home (other family
members, caregivers, nannies, etc.).
List all people living in your household: include siblings, step-children, other relatives:
Name
Age
Relationship to Client
Health/Learning/Behavior Issues
Are there other relatives who have a significant impact on how this child is raised?
Low
Average
High
Very High
Please explain:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
FAMILY HISTORY
Has anyone in the birth family had any of the following psychological disorders?
Check all that apply and list whom.
Learning & Behavior Problems
Condition
Developmental or Cognitive Delay
Speech
or
Communication
Disorder
Intellectual
Disability
ADHD Inattentive/Distractible
AHDD Hyperactive/Impulsive
ADHD Combined
Learning Disability: Reading
Learning Disability: Math
Learning Disability: Writing
Autism Spectrum Disorder
Executive Function Disorder
Speech/Language Disorder
Sensory Regulation Disorder
Conduct Disorder
Oppositional Defiant Disorder
Other ___________________________
Family Member
____________________
____________________
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____________________
____________________
____________________
____________________
____________________
____________________
____________________
Relation to Child
_________________________
_________________________
_________________________
_________________________
_________________________
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_________________________
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_________________________
_________________________
Family Member
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Relation to Child
_________________________
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Physical Disabilities
Condition
Cerebral Palsy
Muscular Dystrophy
Muscular Sclerosis
Hemophilia
Seizure Disorder (Epilepsy/other)
Traumatic Brain Injury
Cystic Fibrosis
Paralysis
Birth Defects
Other ____________________
Family Member
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Relation to Child
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Is there a history in the immediate or extended family of any medical difficulties, illnesses or surgeries? Please
list:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
DEVELOPMENTAL HISTORY
Any difficulties during the pregnancy or delivery of this child? Please list any medications, periods of bed rest,
etc.
lbs,
oz
______ Late
Describe your childs temperament as an infant (e.g., easy-going, irritable, passive, difficult to soothe, etc.)
At what age did your child accomplish these developmental tasks? If your child has not met one or more
milestones, leave those items blank or write not yet.
Early
Speech & Language
Coo/babble
Respond to name
Say first word
Use gestures (wave, point)
Put words together
Speak in sentences
Follow simple directions
Follow multistep directions
Motor Skills
Roll over
Sit alone
Stand alone
Walk alone
Hold pencil correctly
Write legibly
Self-Help/Independence
Feed self
Toilet train
Dress self
Bathe self
Social/Emotional
Smile at others
Laugh aloud
Show affection
Engage in pretend play
First Friendship
Control feelings when upset
Understand others feelings
Show responsibility
On-Time
Late
Approximate Age
MEDICAL HISTORY
Name of Childs Primary Physician: ______________________________
Physicians Address: _____________________________________________
_____________________________________________
Physicians Phone: ___________________________
List any other physicians or health professionals your child sees for services on a regular basis.
___ Excellent
Childs current height:
ft,
Fair
in.
Weight:
Poor
lbs.
Date of last hearing test and who performed (physician, audiologist, school)
Is your child
____right handed
left handed
10
List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or
other medical conditions your child has had.
11
12
Condition
Doctors Name
Doctors Phone
Date Started
Describe your childs regular diet (i.e, favorite and least favorite foods). Do you have any concerns about
your childs eating habits (e.g., aversion to certain tastes, textures, overly restricted eating, overeating,
unhealthy eating)?
What is your childs typical bedtime and wake time each day? Any concerns about your childs sleeping
habits?
Has your child had any previous psychological, psychiatric, or neurological examinations? If so, by whom,
when, and what was your understanding of their findings?
13
MOID inclusion
Audiological services
Visual therapy
Occupational therapy
Physical therapy
Speech/language therapy
Gifted/target program
Tutoring services
Please check all documents and evaluations completed related to the clients disorder(s):
Document/Evaluation
Psychological Evaluation
Neurological Evaluation
Psychiatric Evaluation
Speech/Language Evaluation
Occupational Therapy Evaluation
Physical Therapy Evaluation
Audiological Evaluation
Vision Exam
Hearing Exam
Other _____________________
Date
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Name
of
current
teacher
(s):
___________________________________________________________________________________
What concerns does your childs teacher have about him/her?
If so, which?
If so, which?
Which subjects?
List your childs extracurricular activities, including sports, clubs, hobbies, lessons, etc.:
Sports (list):
Music (list):
Clubs/Groups (list):
Dance (list):
Other:
14
15
Describe your childs strengths, positive qualities, and any special abilities or skills.
Ignore
Have child earn rewards
Give multiple reminders
Time out
Send to room
Take away a privilege
Assign additional chores
Ground child
Reason/Problem solve
Yell at child
Physical punishment
Other:
Very unlikely
1
1
1
1
1
1
1
1
1
1
1
1
Unlikely
2
2
2
2
2
2
2
2
2
2
2
2
Maybe
3
3
3
3
3
3
3
3
3
3
3
3
Likely
4
4
4
4
4
4
4
4
4
4
4
4
Very Likely
5
5
5
5
5
5
5
5
5
5
5
5
Go back and rate the THREE MOST effective strategies. That is, place a 1 by the most effective, a 2 by the
next most effective, and a 3 by the third most effective. Then, please circle the strategy that is LEAST
effective.
Please rate what percentage of discipline is handled by each of the following:
Father:
Mother:
Other:
% (Please specify):
16
Is there anything else we should know about your child that was not covered by this form?
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