Child's Name
*
First Name
Last Name
Child's DOB
*
MM
DD
YYYY
Child's Gender Identity and Preferred Pronouns
*
Child's Current School
*
Grade
*
Teacher
*
Type of Program
*
IEP Classification
*
Current Services
*
Current or Previous Diagnosis?
Referral Source?
*
What concerns do you have about your child?
Child's Primary Address
*
If child does not reside with both parents, please include child’s legal address and custody arrangements:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 1 Name
*
First Name
Last Name
Parent 1 Gender & Preferred Pronouns
*
Parent 1 DOB
MM
DD
YYYY
Parent 1 Address
*
If different from Child's
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 1 Primary Phone Number
*
(###)
###
####
Parent 1 Secondary Phone Number
(###)
###
####
Parent 1 Email
*
Parent 1 Current Employment
Parent 2 Name
First Name
Last Name
Parent 2 Gender & Preferred Pronouns
Parent 2 DOB
MM
DD
YYYY
Parent 2 Address
If different from child's
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 2 Primary Phone Number
(###)
###
####
Parent 2 Secondary Phone Number
(###)
###
####
Parent 2 Email
Parent 2 Education High School
Parent 2 Current Employment
Child's Siblings
Name, Age, Grade and School
Has anyone in the child's immediate family been diagnosed with the following
*
If any of the above were selected, please specify
Relation to child, diagnosis, and date of diagnosis
Has anyone in the child's extended family been diagnosed with the following
*
Length of Pregnancy
Birth Weight
Delivery was:
Check all that apply
Please describe any complications during pregnancy or labor
E.g. German measles, Rh incompatibility, special medical care, false labor, etc.? If so, please describe
Please check any of the following conditions that applied to your child immediately following birth
Please describe any unusual events or problems during the first year
When did your child walk independently?
*
Were there any concerns about gross motor development?
Sitting alone without support, pulling themselves up to a standing position, walking up and down stairs or riding a bike. How coordinated is your child compared to others?
Were there any concerns about fine motor skills?
Please describe any concerns about your child's fine motor development including handwriting, holding utensils, dressing and undressing, or manipulating small objects.
Please describe your child's toilet training process:
When were they bladder trained? Bowel trained? Completely toilet trained? Were there any concerns with this process?
What is your child's primary language?
*
During the first year, other than crying, would you say your child was:
Please describe your child's language development
Did your child babble? At what age did your child say their first words? What were those first words? Baby signing? Any frustration around not being able to communicate? How was their articulation? Did your child use gestures?
How does your child's voice sound?
Does your child 'get stuck,' repeat, or stutter on sounds or words?
E.g. Do they have difficulty finding words or confuse words? Do they mix up syllables?
Does your child have any difficulty hearing or experience periods of hearing loss?
If so, please include the date of their last hearing test and results. Do they have inner ear tubes or frequent ear infections?
Does your child seem to have any difficulty understanding speech or directions?
If so, please describe
Do you experience your child as socially related?
Is your child good at making proper eye contact?
How does your child engage in repetitive or unusual play?
Does your child have a history of pronoun confusion?
Does your child have any preferred objects or activities?
Does your child engage in self stimulatory or tic behaviors?
Does your child perseverate on areas of interest or certain behaviors?
Does your child struggle with any of the following
Please check all that apply
If so, please describe:
Does your child get stuck on thoughts or behaviors, have strong preferences for things to go a certain way, or other kinds of rigidities?
Please describe your child's ability to manage frustration:
Is your child prone to tantrums/meltdowns. What helps to calm them down if so?
Did your child receive Early Intervention Services?
If so please describe the service, date of intervention and child's age.
Please list any professionals you may have consulted in the past regarding your child's development or behavior
Please include the name of the doctor/agency, the date(s) of consultation, and services provided
Please list all psychiatric medications your child has taken in the past
Please include the name of the medication, dates(s) of consumption, reason prescribed, and any benefits or side effects
Present Height
Has your child had any of the following illnesses?
*
Please specify the dates of all illnesses selected above
*
* If you selected 'ear infections,' were tubes inserted and when?
** If you selected other, please specify
Check any of the following diagnoses that apply to your child
*
*If you selected other, please specify
Is your child currently taking any medications regularly?
If so, please specify the medication and Prescribing Physician
Has your child ever been hospitalized for any reason?
If so, please specify the reason, date(s), hospital, and length of stay.
Nursery/Pre-k/Kindergarten
Please specify the location(s) and dates attended, including all institutions your child may have attended before entering 1st grade
Please describe your child's social adjustment during this time
Please describe your child's academic adjustment during this time
Please describe any support services your child received during this time
Please describe any difficulties your child experienced during this time
Elementary School
Please specify the location(s), dates and grades attended, including all institutions your child may have attended before entering middle school
Please describe your child's social adjustment during this time
Please describe your child's academic adjustment during this time
Please describe any support services your child received during this time
Please describe any difficulties your child experienced during this time
Middle School
Please specify the location(s), dates and grades attended, including all institutions your child may have attended before entering high school
Please describe your child's social adjustment during this time
Please describe your child's academic adjustment during this time
Please describe any support services your child received during this time
Please describe any difficulties your child experienced during this time
High School
Please specify the location(s), dates and grades attended, including all institutions your child may have attended before entering college
Please describe your child's social adjustment during this time
Please describe your child's academic adjustment during this time
Please describe any support services your child received during this time
Please describe any difficulties your child experienced during this time
College
Please specify the location(s), dates and grades attended, including all institutions your child may have attended and degrees attained
Please describe your child's social adjustment during this time
Please describe your child's academic adjustment during this time
Please describe any support services your child received during this time
Please describe any difficulties your child experienced during this time
