Background Information Form

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:

Is this child adopted:

Yes

Child's age at adoption:

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:

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

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

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

Has your child been retained a grade?

Yes

If yes, which grade?

Did your child attend preschool or daycare?

Yes

Were there any early concerns regarding learning or behavior?

Yes

Has the child been placed in special education programs currently or in the past?

Yes

Does your child have a learning disability (LD)?

Yes

If yes, which subjects?

Does your child have a language disorder?

Yes

If yes, which type?

If yes, where?

Does your child receive tutoring?

Yes

Does your child receive special education/ 504 / Other Health Impaired (OHI) services?

Yes

Birth and Developmental History:

Length of pregnancy:

Illness or complications while pregnant?

Yes

If yes, please explain:

Medications used during the pregnancy:

Substances used during the pregnancy (frequency, quantity, type):

Was your child’s birth normal?

Yes

Were there any concerns at birth related to lack of oxygen (e.g., born “blue”?):

Yes

Birth weight:

Length:

Did mother or baby stay in Special or Intensive Care?

Yes

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

Has your child received speech therapy?

Yes

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

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

If yes, for how long?

Has your child been diagnosed with a chronic health condition?

Yes

If yes, please describe:

Does your child take any medication on a regular basis?

Yes

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

If yes, please give the name of previous therapist:

May I contact this provider?

Yes

If yes, please provide phone number:

Has the child received previous educational or neuropsychological testing?

Yes

If yes, please list the month and year in which testing was completed:

Has your child experienced any of the following:

Being teased or bullied

Teasing/bullying others

Peer rejection

Popularity with peers

Please list any other areas of concern or information you feel I need to know in the area below: