Child's name
*
First Name
Last Name
Date of birth
Child's age
Gender
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
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Name of person completing questionnaire
Your relationship to the child
Parent/Guardian name
Relationship to child
Age
Address (if different from child’s)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
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Highest level of education
Occupation
Employer
Parent/Guardian name
Relationship to child
Age
Address (if different from child’s)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
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Highest level of education
Occupation
Employer
Please list all people living in home
Name / Age / Relationship to child
Mother: Health, learning, mental health problems? (please specify)
Father: Health, learning, mental health problems? (please specify)
Child’s siblings: Health, learning, mental health problems? (please specify)
Have any family members ever received additional help in school, early intervention, or special education services?
If yes, specify who and the reason
Primary language spoken in the home
Other languages spoken in the home
Have there been any major changes within the family or the child’s living situation that have affected your child’s functioning?
e.g., moves, divorces, deaths, etc.
If yes, describe below
Event / Date / Child’s Age
Did the child’s mother receive prenatal care during the pregnancy?
Mothers Age when she gave birth
Did the mother have any of the following during or immediately before/ after the pregnancy
Check all that apply
If other, please explain
If maternal injury, please describe
If hospitalized during pregnancy, please give reason
Were any of the following used during pregnancy?
Check all that apply
If other, please specify:
Was infant born full term?
Number week gestation
Type of delivery
Describe any complications during delivery
Did your child have any medical issues at birth?
e.g., seizures, jaundice, cord around the neck, meconium aspiration, required oxygen
If yes, please describe:
How soon after birth was the baby discharged from the hospital?
Clinic Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
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Has your child had a previous psychological/ psychiatric/ neuropsychological evaluation?
If yes, where was your child evaluated and by whom?
When?
Has your child been given any medical diagnoses? If yes, please describe:
Has your child had any surgeries or hospitalizations?
Age
Reason
Other details
Has your child experienced any major accidents or injuries:
Age
Does your child have any allergies?
If yes, please explain:
Does your child have any problems with vision?
If yes, please explain:
Does your child have any problems with hearing?
If yes, please explain:
Drug Name:
Who Prescribes?
For what problems?
Dose
Date Started
MM
DD
YYYY
Benefits
Side Effects
Age rolled over
Age sat alone
Age crawled
Age walked
Which hand does your child use most?
Do you have any concerns about your child’s motor development?
Please specify
Age spoke single words
Age spoke in 2-word phrases
Age used sentences
Difficulty with pronunciation?
Does child understand simple commands?
Do you have any concerns about your child’s speech or language?
Please specify
Has your child ever required physical, occupational or speech/language therapy?
If yes, therapist's name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Type of therapy and for what issues
When?
Did you find it helpful?
Did your child have toileting accidents after toilet training?
If yes, please explain
Has your child ever lost skills that at one time he/she was able to perform?
If yes, please explain
As an infant and toddler, were any problems noted in the following areas with this child?
If other, please describe
As an infant and toddler, was your child interested in social contact?
Eye contact, social smile, showing things, sharing experiences
If no, please describe
Name of current school
Grade
Teacher's name
Has your child ever repeated a grade?
If yes, what grade?
Has your child ever been suspended or expelled?
If yes, for what reason?
Is your child absent from school frequently?
If yes, for what reason?
Has your child had special education testing in school?
Is your child on an IEP (Individual Education Plan)?
If yes, for what reason?
Does your child have a Section 504 Plan?
If yes, for what reason?
Overall school performance
Reading
Writing
Mathematics
Relationship with teachers
Relationship with peers
Participation in school-based activities
What are your main concerns about your child? Please provide examples when possible
Has your child had a previous psychological/ psychiatric/ neuropsychological evaluation?
If yes, where was your child evaluated and by whom?
When?
Has your child been given any of the following diagnoses?
If other, please specify
Has your child ever had psychological counseling or therapy?
If yes, therapist’s name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
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Type of therapy and for what issues
When?
Did you find it helpful?
What are you hoping to achieve from this evaluation?
What are your child’s personal strengths?
