Please list the name of the school, address, and phone number if possible.
If other, please specify your ethnicity.
Please indicate the names of any childcare providers, the age at the time of care, and the length of time.
If you wish us to contact a parent of family member not in the current household, please provide his or her name(s) and phone number(s).
Please list all adults and children living in the household, including age, gender, and relationship to child.
What concerns do you have and why are you seeking help at this time?
What kind of information or assistance are you hoping to obtain?
Are any concerning behaviors or behavior problems? If yes, please describe:
Are there any specific concerns / problems with studying and/or learning problems? If yes, please describe:
Please describe any other problems that may be of relevance to this evaluation:
Please describe three or four strengths:
Please describe two or three weaknesses:
Please list all past neurological, psychiatric, psychological, neuropsychological, eduactional, speech & language, or other types of evaluations administered.
Please list all past or present interventions, treatment, or remediation the child has received or is receiving, including Physical Therapy, Occupational Therapy, Speech, and Language Therapy, etc.:
Describe any difficulties in conception and/or complications that occured during pregnancy:
Where there any complications or difficulties during labor and delivery?
If yes, give name and location of child caregiver.
If yes, describe:
If yes, please give name and location of preschool.
If there where problems, please describe:
If yes, please give name and location of school:
If yes, describe:
If yes, please describe:
Please list name, location of school, and grades attended:
Please list name, location of school, and grades attended:
Please list name, location of school, and grades attended:
Please list the name and address of current school:
meningitis, encephalitis, stroke, brain
hemorrhage, narcolepsy, sleep disorders, head injury, coma, loss consciousness, tumor, toxic
metal exposure, headaches, seizures, tics, fainting, tremor, vertigo? If so, describe:
cerebral palsy, muscular dystrophy, multiple sclerosis, mental retardation, central nervous system structural defect? If so, describe:
Tourette syndrome, learning disabilities, dyslexia, ADD/ADHD, autism, Asperger syndrome, hyperlexia, processing deficits, obsessive compulsive disorder, oppositional defiant disorder, nonverbal learning disability, executive function deficits? If so, please describe:
If so, please describe:
emotional/behavior disorders, depression,
manic/depression, bipolar disorder, schizophrenia, phobias, panic attacks, anxiety, eating disorder? If so, describe:
Have you (or your child) been a victim of emotional, physical, or sexual abuse? If so, describe:
If yes, please describe:
If yes, please describe:
How would you describe your or the clients temperament and personality?
