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Child's Name:

Date of Birth:

Race:

Ethnicity:

Completed By:

Relationship:

Today's Date:

Email:

Section 1: Family Information

Parents/Legal guardians:

Name:

Relationship to Child:

Date of Birth:

Highest Education Level:

Occupation:

Name:

Relationship to Child:

Date of Birth:

Highest Education Level:

Occupation:

Are the biological parents together?

Yes

No

Were the biological parents ever together?

Yes

No

How old was child when parents separated/divorced?

Who has primary physical custody of the child?

Mother

Father

Other

If other:

Additional Information

Who is the primary caretaker?

Mother

Father

Other

If other:

Who is the primary disciplinarian?

Mother

Father

Other

If other:

Please list all individuals that live in the home with the child.

Name	Relationship to Child	Age	Biological Relative?

Does your child live in another household part-time (e.g. parents share custody):

Yes

No

If yes, indicate what the schedule is between households:

Please list all individuals that live in this home with the child.

Name	Relationship to Child	Age	Biological Relative?

What is the dominant language spoken in the home?

Has Child Protective Services or a similar agency ever been involved with the family?

Yes

No

Please explain:

Are all caregivers aligned in their parenting approach?

Yes

No

N/A

Do any caregivers argue about difference in parenting style?

Yes

No

N/A

Please explain:

Do caregivers support each other when disciplining the child?

Yes

No

N/A

What is the level of stress for each caregiver? (1 being not stressed at all and 5 being very stressed)

Caregiver 1

Level

0

Caregiver 2

Level

0

Has your child had any changes in caregivers?

Yes

No

Please explain.

Does your family identify with any particular religion?

Section 2: Infancy and Development History

Toilet Training

Age of toilet training:

Urinating

Bowel Movement

After your child was fully trained, did he/she have any problems with:

Bed wetting:

Historically

Yes

No

Currently

Yes

No

Soiling problems:

Historically

Yes

No

Currently

Yes

No

If yes, please describe.

Motor Development

Indicate which is your child's dominant hand (e.g. writes with, eats with, throws with):

Right

Left

Both

Has your child ever received occupational therapy?

Yes

No

Child's age when services started.

Describe treatment and progress. (Please bring any reports that you have to your first appointment).

Are they still receiving the therapy?

Yes

No

What age did they stop?

Please bring any reports that you have to your first appointment.

Has your child ever received physical therapy?

Yes

No

Child's age when services started.

Describe treatment and progress. (Please bring any reports that you have to your first appointment).

Are they still receiving the therapy?

Yes

No

What age did they stop?

Please bring any reports that you have to your first appointment.

Language Development

Has your child ever received speech/language therapy?

Yes

No

Child's age when services started.

What speech or language areas were the focus of therapy? (check all that apply)

Articulation (i.e. pronunciation)

Pragmatic Language (i.e. using vocal tone, pitch, etc. to convey meaning of a social or emotional nature to others

Expressive Language (i.e. what the child can say)

Receptive Language (i.e. what the child can understand)

Other

Please explain.

Are they still receiving the therapy?

Yes

No

What age did they stop?

Please bring any reports that you have to your first appointment.

Early Intervention

Has your child ever received Early Intervention Services?

Yes

No

Please explain.

Has your child ever received services through the Committee on Preschool Special Education?

Yes

No

Section 3: Pregnancy and Birth Information

Please select the answers that best describe any complications during your pregnancy with this child:

If you took medications during your pregnancy, please list them here.

If you answered 'Yes' to any of the above, please provide additional details.

Original Due Date

Birth Weight

Apgar Score's

Was your child born premature?

Yes

No

How many weeks premature?

Type of Delivery

Were forceps or vacuum used during delivery?

Yes

No

Did your child experience any loss of oxygen during delivery or following birth?

Yes

No

Is there any other information about your pregnancy that you feel is important for us to know?

*Please bring birth records with you if you experienced any complications during pregnancy or birth of your child.

Section 4: Medical Information and History

Indicate whether the child has ever had any of the following

If your child has had any of the above, please provide further detail.

Age of most recent eye exam:

Does child wear glasses?

Yes

No

Has your child ever been assessed or treated by a...

*If yes, please bring any reports that you may have to the first appointment.

Psychologist

Yes

No

Name of physician

Date treated

Any medications currently or previously prescribed

Psychiatrist

Yes

No

Name of physician

Date treated

Any medications currently or previously prescribed

Neurologist

Yes

No

Name of physician

Date treated

Any medications currently or previously prescribed

Additional medical information.

Has your child ever had any psychological or neuropsychological testing done before?

Yes

No

If yes, please bring copies of any testing reports to the first appointment.

By whom	Date	Test	Outcome

List all medical professionals (physicians, psychologists, therapists) that your child is currently seeing:

Name	Title (specialty)	Reason for Seeing	Dates of Service

If this page is not applicable, simply advance to the next page.

Please list all current medications your child is prescribed.

If you need more space, please bring a list of all medications to your first appointment.

Is your child currently taking any medications for emotional, behavioral, or sleep problems?

Yes

No

If yes, please complete the table below with information about the medications.

Medication	Treatment of What Condition	Dosage	How many times per day is medication taken?	How long has your child been on this dosage?	Is Rx effective?

Please list all previous medications your child has been prescribed.

If you need more space, please bring a list of all medications to your first appointment.

Has your child previously taken any medications for emotional, behavioral, or sleep problems?

Yes

No

If yes, please complete the table below with information about the medications.

Medication	Treatment of What Condition	Dosage	How long was your child on this dosage?	Why was this medication discontinued?

Section 5: School Information and History

Does your child attend school?

Yes

No

*If "NO", you may simply disregard the following section and continue to the next page.

School

District

Current Grade

Does your child attend an extended year program?

Yes

No

What grade did it begin?

Does your child have a 504 Plan?

Yes

No

Does your child have an IEP?

Yes

No

What grade did it begin?

If yes, please bring a copy of the most recent IEP and/or 504 plan to your first appointment.

What type of classroom is your child placed in?

Regular

Special Ed

Please describe

What is your child's weakest subject?

What is your child's strongest subject?

Has your child ever failed a grade or been retained?

Yes

No

Which grade(s)?

Has your child ever been expelled or suspended?

Yes

No

When and why?

Has your child's school ever completed intelligence or achievement testing?

Yes

No

*If yes, please bring copies of any reports to your first appointment.

Section 6: Social History

Does your child have difficulty with the following:

Getting along with siblings?

Yes

No

Please explain.

Getting along with adults?

Yes

No

Please explain.

Making friends?

Yes

No

Please explain.

Keeping friends?

Yes

No

Please explain.

Does your child get invited to parties or sleepovers?

Yes

No

Does your child have a best friend?

Yes

No

Does your child have peers who come over to play or attend his/her parties?

Yes

No

Does your child participate in sports or extracurricular activities?

Yes

No

What special interests does your child have?

Section 7: Family History

Please indicate if anyone in the biological family related to the child (e.g. parents, cousins, grandparents, siblings) has the following:

As parents/caregivers, do you have any of the above noted problems (e.g. anxiety/depression)? If yes, please indicate your history of problems/treatment and whether you are currently receiving treatment:

Please use this space to provide any further information for items listed above.

Youth Medical & Developmental History Form

Section 1: Family Information

What is the level of stress for each caregiver? (1 being not stressed at all and 5 being very stressed)

Section 2: Infancy and Development History

After your child was fully trained, did he/she have any problems with:

Motor Development

Language Development

Early Intervention

Section 3: Pregnancy and Birth Information

Section 4: Medical Information and History

Has your child ever been assessed or treated by a...

If this page is not applicable, simply advance to the next page.

Please list all current medications your child is prescribed.

Please list all previous medications your child has been prescribed.

Section 5: School Information and History

*If "NO", you may simply disregard the following section and continue to the next page.

Section 6: Social History

Does your child have difficulty with the following:

Section 7: Family History

All done!

Press submit to complete the form.