Beacon Assessment Center Developmental Questionnaire Please complete prior to your first appointment
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1 Beacon Assessment Center Developmental Questionnaire Please complete prior to your first appointment If you would prefer to complete the electronic version of this questionnaire on the Beacon Assessment Center website, please visit BEACON ABAServices CONTACT INFORMATION: Client Name: Age: DOB: Grade: Dates of Evaluation: Gender: M F Language(s) spoken in the home: Name of person completing questionnaire: Relationship to the Child: Father s (or Parent 1) Name: Address: Address: Telephone: Mother s (or Parent 2) Name: Address: Address: Telephone: Name & Address of Pediatrician: Person who referred child for this evaluation (include relevant titles): Health Insurance: Policy #: REASON FOR REFERRAL: Chief Complaint (include previous diagnoses): Please describe child s strengths: Please describe child s weaknesses: What are you hoping to gain from this evaluation? Beacon ABA Services, Inc. 2016
2 FAMILY HISTORY: Any history of learning challenges (i.e., reading, writing, math) within the family? Any family history of developmental delays (i.e., Autism, intellectual disability)? Any family history of problems with the regulation of attention or behavior? Any neurological or genetic conditions within the extended family? Any family history of mood disorders (i.e., bipolar) or psychiatric conditions (i.e., anxiety, schizophrenia)? Parents marital status: YES NO Comments: Married Never Married Divorced/Separated Widowed If never married/separated/ divorced, is there joint custody? [Note: If so, both parents need to provide written permission for the evaluation to commence.] Contact with non-custodial parent or custody arrangement if any: Highest level of maternal education: Highest level of paternal education: Was the child adopted? Any history of trauma, abuse, or neglect? Does the child have any involvement with DCF? Contact information for DCF Case Worker: Please describe family composition including people currently living in the home (i.e., siblings ages): Any siblings living outside the home? Any concerns regarding sibling s health, development, learning or behavior? Beacon ABA Services, Inc Page 2 of 6
3 BIRTH HISTORY: Complications with this pregnancy? Maternal medications during pregnancy? Units of alcohol consumed per week during pregnancy: Exposure to drugs or other toxins while in utero? Was child born full term? Problems with labor/delivery? Birth weight lbs. oz. Was child jaundiced? Any other complications noted at birth? Were newborn supports required? Did baby require Intensive Care Nursery? INFANT TEMPERMENT: Did child have early feeding challenges? Problems with sleep during infancy? Difficult temperament (i.e., colic or excessive crying)? Did child respond to soothing efforts? Was child passive, shy, withdrawn during the infant or toddler period? MEDICAL HISTORY: Any diagnosed genetic or medical conditions? Problems with vision? Concerns about hearing? Date of most recent hearing test: History of ear infections? How Many? Heart defects? History of serious illness? Hospitalizations? Surgeries? Serious injury (i.e., broken bones)? Seizures, convulsions, staring spells? Head injury or loss of consciousness? Allergies? Reflux, constipation, or other gastrointestinal issues? Problems with feeding (i.e. chewing, swallowing) or restricted diet? Problems with sleep (i.e., night waking, night terrors?) Please list all medications that are current. Please list all past medications. YES NO Comments: YES NO Comments: YES NO Comments (when?): Results: Beacon ABA Services, Inc Page 3 of 6
4 DEVELOPMENTAL HISTORY: Sat by 8 months? Crawled by 10 months? Walked by 15 months? Problems with motor coordination (i.e., riding a bike, catching a ball)? Hand preference: When did handedness emerge? Toilet trained by 3 ½? Night trained by age 5? Did the child have difficulty within the social domain? Did the child show appropriate play skills (i.e., toy play, pretend play, imaginary/fantasy play, cooperative play) Were there behavioral difficulties? (please describe) Did child struggle with the acquisition of early school skills (i.e., learning colors, alphabet, counting)? LANGUAGE HISTORY: Babbled by 10 months? Used first word by 12 months? Used two word phrases by 24 months? Used/uses gestures to communicate? Used/uses pictures or symbols to communicate? Child s primary mode of communication: Does your child have difficulty identifying objects or people by name? Does your child have difficulty understanding what is said to them or following instructions? Does your child have problems naming common objects, people, or events? Does your child have difficulties with expressive language (i.e., forming sentences, answering questions, explaining problems)? Do other people understand your child s speech (i.e., problems with stuttering, articulation)? Does your child initiate or engage in social interactions/conversation with others adults or children? Does your child seem aware of the difficulties they have communicating? YES NO Comments (When?): Right Left mixed non-dominance. YES NO Comments (When?): cries/whines vocalizations AAC gestures speech Other: Beacon ABA Services, Inc Page 4 of 6
5 SOCIAL/BEHAVIORAL PROFILE: Please review the following behaviors and see if they describe your child: Poor or limited eye contact Does not use gestures or pointing to communicate or share attention Does not use words to express wants and needs Echoes words or repeats phrases Speaks in unusual tone or manner Hard to get child s attention Seems preoccupied, aloof, or distant Repetitive behaviors (e.g., flaps hands, moves body or fingers in unusual way, toewalks, engages in unusual visual behaviors). Please list any others. Prefers to be alone; ignores others Difficulty relating to peers or making friends Unusual play behaviors; limited pretend play Has unusual or intense interests Takes things overly literally; misses the point or has difficulty with figurative language/idioms/slang Handles change poorly; insists on sameness Sensory Issues (please list) Tantrums/Meltdowns (if yes, how frequent) Difficulties related to Attention/Impulsivity/Overactivity Not True Sometimes True Very True PREVIOUS EVALUATIONS & TREATMENTS: School Testing Date Grade Type of Testing (i.e., Psychological, Speech & Language, Occupational Therapy, Educational Testing) Other Evaluations (i.e., psychologist/neuropsychologist, neurologist, other specialists) Date Professional s Name Results Medical Tests (i.e., EEG, MRI, Chromosome tests, genetic tests) Date Type of Testing Results Beacon ABA Services, Inc Page 5 of 6
6 SERVICE HISTORY: Does your child receive any of these services? (Have they in the past?) YES NO If yes, when? Early Intervention Speech Therapy Occupational Therapy Physical Therapy Special Education Services Repeated a grade? Has child undergone a previous neuropsychological assessment? Existing diagnoses? (Indicate which ones) Has your child been tested by any professionals including school personnel within the last 12 months? Current grade and services (IEP? 504? please describe services): Please list any involved professionals and contact information Psychologist/therapist: Psychiatrist: Advocate: PLEASE ATTACH A CURRENT PHOTOGRAPH OF YOUR CHILD Beacon ABA Services, Inc Page 6 of 6
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