Developmental History:
Family History:
Child is living with:
Is this child adopted:
Status of parents' marriage:
Educational History:
Do you feel your child is learning up to his or her potential? If no, please indicate the academic areas that are underdeveloped:
1) Mathematcs
2) Reading
3) Writing
4) Language:
Please check any other concerns or problem your child has in school:
Has your child been retained a grade?
Did your child attend preschool or daycare?
Were there any early concerns regarding learning or behavior?
Has the child been placed in special education programs currently or in the past?
Does your child have a learning disability (LD)?
Does your child have a language disorder?
Does your child receive tutoring?
Does your child receive special education/ 504 / Other Health Impaired (OHI) services?
Birth and Developmental History:
Illness or complications while pregnant?
Was your child’s birth normal?
Were there any concerns at birth related to lack of oxygen (e.g., born “blue”?):
Did mother or baby stay in Special or Intensive Care?
Any speech hearing or language difficulties?
Has your child received speech therapy?
Overall rate of development:
Medical History
Has the child been taken to the emergency room with a serious emergency, hospitalized, or had outpatient surgery since birth?
If the child had a head injury: Did they lose consciousness?
Has your child been diagnosed with a chronic health condition?
Does your child take any medication on a regular basis?
Behavioral and Mental Health History:
Has the child or family received any professional mental health treatment, such as individual or family counseling, group counseling, etc.?
May I contact this provider?
Has the child received previous educational or neuropsychological testing?
Please check all traits that apply to the child NOW:
Interactions with peers:
Has your child experienced any of the following:
Has your child or any of your family members struggled with depression/sadness?
Anxiety/excessive worries?
Panic attacks?
Tics: vocal/motor?
Suicidal thoughts?
Attempted suicide?
Learning disability?
Problems with anger?
Problems with assertiveness?
Opposition or defiance?
Problems with the law?
Nervous breakdown?
Heavy alcohol use?
Drug use?
Eating disorder?