Mary Ellen Weissman, Ph.D.
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Background Information Form
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Developmental History:
Child's first name:
Birth date:
Age:
Name of parent/guardian:
Home address:
City:
State:
ZIP:
Today's date:
Home phone:
Cell phone:
E-mail:
Emergency contact's name:
Phone:
Person completing form:
Relationship to child:
Child's birthplace:
What are your primary concerns for your child?
Who referred you to me?
Family History:
Child is living with:
Both parents
Mother
Father
Grandparent(s)
Mother & Stepparent
Father & Stepparent
Legal Guardian
Other
Is this child adopted:
Yes
No
Child's age at adoption:
Status of parents' marriage:
Married
Seperated
Divorced
Widowed
Single
How long married?
How long divorced?
Child's age at divorce:
Father's name:
Age:
Education:
Employed:
Work phone:
Type of work:
Mother's name:
Age
Education:
Employed:
Work phone:
Type of work:
List the people who live at home (name, age, relationship to child, occupation):
Please provide any information about your child's immediate/extended family that might help us understand the child’s needs (e.g., medical, developmental, behavioral, educational, emotional, or psychological):
Educational History:
Current grade:
Name of school:
Phone number:
Teacher's name:
Type of school:
Choose an option
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How does the school describe your child’s classroom behavior?
What does your child do best at school?
What are your child's strengths?
Please list any extracurricular activities your child is involved in:
Do you feel your child is learning up to his or her potential? If no, please indicate the academic areas that are underdeveloped:
Yes
No
1) Mathematcs
Problems with acquisition of mathematical facts
Careless errors
Difficulty performing simple arithmetic (e.g., addition, subtraction, division)
Difficulty understanding word-problems
Other
2) Reading
Difficulty matching letter sounds to written symbols
Difficulty pronouncing words (especially long ones)
Reading is “choppy” or non-fluent
Difficulty with reading comprehension
Other
3) Writing
Poor pencil grip
Letters too big
Inconsistent spacing / inconsistent handwriting
Difficulty expressing ideas in writing
Poor spelling
Other
4) Language:
Difficulty finding words to name objects
Takes a long time to get a thought across
Difficulties understanding or following directions even when paying attention
Other
Please check any other concerns or problem your child has in school:
Does not do homework
Poor handwriting
Does not remain seated
Incomplete classroom work
Messy/disorganized
Excessive time to complete assignments
Forgets assignments
Starts but does not finish homework
Excessive talking
Poor attention in class
Distracted
Test Anxiety
Noncompliant in class
Fails to check homework
Makes careless errors
Has your child been retained a grade?
Yes
No
If yes, which grade?
Did your child attend preschool or daycare?
Yes
No
Were there any early concerns regarding learning or behavior?
Yes
No
Has the child been placed in special education programs currently or in the past?
Yes
No
Does your child have a learning disability (LD)?
Yes
No
If yes, which subjects?
Does your child have a language disorder?
Yes
No
If yes, which type?
If yes, where?
Does your child receive tutoring?
Yes
No
Does your child receive special education/ 504 / Other Health Impaired (OHI) services?
Yes
No
Birth and Developmental History:
Length of pregnancy:
Illness or complications while pregnant?
Yes
No
If yes, please explain:
Medications used during the pregnancy:
Substances used during the pregnancy (frequency, quantity, type):
Was your child’s birth normal?
Yes
No
Were there any concerns at birth related to lack of oxygen (e.g., born “blue”?):
Yes
No
Birth weight:
Length:
Did mother or baby stay in Special or Intensive Care?
Yes
No
Please describe any problems:
Please list any other problems or comments regarding infancy or early childhood development:
Please list (in months) the age your child sat on their own
Please list (in months) the age your child stood up holding onto furniture
Please list (in months) the age your child walked alone
Any concerns with your child’s gross motor development (e.g., running, skipping, jumping):
Please list (in months) the age your child fed themselves with a spoon
Please list (in months) the ages your child scribbled:
Please list (in months) the ages your child tied shoes:
Any concerns with your child’s gross motor development (e.g., running, skipping, jumping):
Please list (in months) the ages your child used single words:
Please list (in months) the ages your child used 2+ word-sentences:
Please list (in months) the ages your child described a thought:
Any speech hearing or language difficulties?
Yes
No
Has your child received speech therapy?
Yes
No
Potty trained/day:
Potty trained/night:
Overall rate of development:
Slow
Normal
Fast
Medical History
Pediatrician's Name:
Phone number:
Has the child been taken to the emergency room with a serious emergency, hospitalized, or had outpatient surgery since birth?
Yes
No
If yes, please describe condition/injury, treatment, any surgery, how long, and where:
If the child had a head injury: Did they lose consciousness?
Yes
No
If yes, for how long?
Has your child been diagnosed with a chronic health condition?
Yes
No
If yes, please describe:
Does your child take any medication on a regular basis?
Yes
No
If yes, please list the name and dosage:
Behavioral and Mental Health History:
Please describe any behaviors that are particularly concerning to you or others:
Please list any unusual, traumatic, or possibly stressful events in the child’s life that you think may have had an impact on his or her development and current functioning. Include incident, child’ age at the time, and comments.
Has the child or family received any professional mental health treatment, such as individual or family counseling, group counseling, etc.?
Yes
No
If yes, please give the name of previous therapist:
May I contact this provider?
Yes
No
If yes, please provide phone number:
Has the child received previous educational or neuropsychological testing?
Yes
No
If yes, please list the month and year in which testing was completed:
Please check all traits that apply to the child NOW:
Sad
Overactive
Cooperative
Quiet
Happy
Independent
Tantrums
Defiant
Leader
Dependent
Lethargic
Even-tempered
Follower
Sensitive
Loner
Moody
Affectionate
Sleep problems
Difficult to discipline
Interactions with peers:
No friends
Few friends
Loses friends
Trouble making new friends
Mean, aggressive
Too shy or too timid
Bossy, controlling
Risky behaviors
Has your child experienced any of the following:
Being teased or bullied
Teasing/bullying others
Peer rejection
Popularity with peers
Has your child or any of your family members struggled with depression/sadness?
Child current
Child past
Mother
Father
Sibling
Other
Anxiety/excessive worries?
Child current
Child past
Mother
Father
Sibling
Other
Panic attacks?
Child current
Child past
Mother
Father
Sibling
Other
Obsession/compulsions?
Child current
Child past
Mother
Father
Sibling
Other
Tics: vocal/motor?
Child current
Child past
Mother
Father
Sibling
Other
Headaches?
Child current
Child past
Mother
Father
Sibling
Other
Suicidal thoughts?
Child current
Child past
Mother
Father
Sibling
Other
Attempted suicide?
Child current
Child past
Mother
Father
Sibling
Other
Learning disability?
Child current
Child past
Mother
Father
Sibling
Other
ADHD?
Child current
Child past
Mother
Father
Sibling
Other
Problems with anger?
Child current
Child past
Mother
Father
Sibling
Other
Problems with assertiveness?
Child current
Child past
Mother
Father
Sibling
Other
Opposition or defiance?
Child current
Child past
Mother
Father
Sibling
Other
Problems with the law?
Child current
Child past
Mother
Father
Sibling
Other
Schizophrenia/psychosis
Child current
Child past
Mother
Father
Sibling
Other
Schizophrenia/psychosis?
Child current
Child past
Mother
Father
Sibling
Other
Nervous breakdown?
Child current
Child past
Mother
Father
Sibling
Other
Heavy alcohol use?
Child current
Child past
Mother
Father
Sibling
Other
Drug use?
Child current
Child past
Mother
Father
Sibling
Other
Eating disorder?
Child current
Child past
Mother
Father
Sibling
Other
Abuse/neglect?
Child current
Child past
Mother
Father
Sibling
Other
Please list any other areas of concern or information you feel I need to know in the area below:
Submit