INTAKE INFORMATION BASIC INFORMATION. Gender: (circle) Male Female Race: (circle) White Black Other. Special Education Placement/Services (if any):

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1 INTAKE INFORMATION BASIC INFORMATION Child s Name: Today s Date: Gender: (circle) Male Female Race: (circle) White Black Other Birth Date: Parent/Guardian: Home Address: City: State: ZIP School/Daycare: Address: Child s Age: years Relation to Child: Home Phone: Business Phone: Parish: Grade: Phone: Special Education Placement/Services (if any): Person Completing this Form: (circle) Mother Father Stepmother Stepfather Other Who referred you here? Address: Title: Phone: PRESENTING PROBLEMS Briefly describe your child s current difficulties: How long has this problem been a concern to you? When was this problem first noticed? What seems to make this problem worse? Have any other family members had similar problems? Yes No If yes, whom? Previous evaluation or treatment for current problems/similar problems? Yes No If yes, when and with whom? If currently, list address: Is your child on any medication at present? Yes No If yes, please list names of medications:

2 DEVELOPMENTAL HISTORY PREGNANCY: Duration of pregnancy (weeks/moths): During pregnancy, did the mother: suffer from illness or disease suffer from an accident undergo surgery take medication undergo x-ray studies smoke tobacco consume alcohol use drugs amniocentesis Complications of pregnancy included: excessive vomiting excessive staining or blood loss threatened miscarriage infection(s) toxemia diabetes high blood pressure poor nutrition loss of consciousness in mother DELIVERY: Duration of Labor: hours Birth Weight? lbs. ozs. Length: Type of Labor: Spontaneous Induced Forceps Used? Yes No Type of Delivery: Normal Breach Caesarean Complications: None Cord around neck Hemorrhage Placenta problems Delay in breathing Injury to infant Other (specify) NEWBORN AND POST-DELIVERY PERIOD: Total days baby was in hospital after delivery: Was baby in NICU? Yes No How long? Medications administered to baby: Complications: None Jaundice (yellow skin) Intraventricluar hemorrhage Addiction Infection Meconium staining/aspiration Anemia Seizures Respirator and/or resuscitation Birth defects Trouble breathing was required Vomiting Cyanosis (turned blue) Diarrhea INFANCY-TODDLER PERIOD: As a baby, the child was: Active Difficult Shy Hard to please Cranky Easy Sleepy Lazy or slow moving Calm Happy Social Persistent Were any of the following present during the first years of life?

3 colic constantly into everything feeding problems slow or unable to adapt to changes in routine sleeping problems excessively high or low activity level (circle one) frequent head banging was not calmed by being held and/or stroked excessive restlessness excessive number of accidents compared to other did not enjoy cuddling children withdrawal or other problems adjusting to new people and situations viariable or irregular body functions (sleep, hunger, bowel movements, etc.) Were there any special problems in the growth and development of your child during the first year? Yes No If yes, then describe: DEVELOPMENTAL MILESTONES: The following is a list of infant preschool behaviors. Please indicate the age at which your child first demonstrated each behavior. If you are not certain of the age, but have some idea, write the age followed by a question mark. If you do not remember the age at which the behavior occurred, please write a question mark. Behavior Age Behavior Age Walked alone Stayed dry at night Spoke first word Fed Self Put several words together Rode tricycle Became toilet trained Compared with other children, the child s early development was: Normal Delayed Advanced EDUCATIONAL HISTORY Current Grade: Grade(s) Repeated Describe academic and any other classroom problems: Previous School Interventions: Describe recent school performance (list report card grades): Describe special services received: Current educational problem areas include: Describe special services received:

4 Current educational problem areas include: reading does not respect rights of others cheats arithmetic fights with classmates inattentive spelling detentions and/or suspension distracted writing does not like school disrupts class other subjects does not complete homework overactive/fidgety poor study skills difficulty remembering does not work well independently conflict with teacher(s) worries about school excessive absences (reason: ) When did school problem begin or first come to your attention: HOME INFORMATION Mother s Name: Age: Education: Father s Name: Age: Education: Stepmother s Name: Age: Education: Stepfather s Name: Age: Education: Identify the adults involved in the child s life. Do they reside in the child s home? IN OUT biological mother biological father stepmother stepfather adoptive mother adoptive father foster mother foster father aunt uncle grandmother grandfather other relative friend other HOME INFORMATION - CONTINUED Mother s age at first pregnancy Mother s marital status at first pregnancy: Married Unmarried Marital status at this child s birth: Married Unmarried Divorced Separated Widowed

5 If parents are separated or divorced, how old was child when the separation occurred: What are the current custody/visitation arrangements? Was your child adopted? Yes No Date of Adoption: Age at Adoption: List of all people living in household: NAME RELATIONSHIP TO CHILD AGE List any brothers or sisters (including stepfamily) who live outside the household: Describe any other important info about home: CHILD S MEDICAL HISTORY Place a check next to any illness/condition that your child has. When you check an item, also note the approximate date for child s age at the time of the illness: ILLNESS OR CONDITION AGE/DATES ILLNESS OR CONDITION AGE/DATES AIDS or HIV positive Fainting Spells Allergies Fetal Alcohol Syndrome Anemia Fever(if high or prolonged) Aneurysm Guillain-Barre Syndrome Anoxia Head Injury Arteriovenous Malformation Headaches Arthritis Heart Disease or Problems Asthma Lead Poisoning Ataxia Hepatitis Auto Accident Herpes Back Pains or Problems High Blood Pressure Bleeding Problems Jaundice Blood Disorders Leukemia Bone or Joint Disease Malnutrition Broken Bones Meningitis Cancer Muscular Disease Page - 6 CHILD S MEDICAL HISTORY - CONTINUED ILLNESS OR CONDITION AGE/DATES ILLNESS OR CONDITION AGE/DATES Chorea Pain Problems Coma Paralysis Cystic Fibrosis Pituitary Disorder Dazed or Unconscious Pneumonia Dementia Poisoning Diabetes Poliomyelitis Dysarthria Rheumatic Fever Dysphasia (or Apraxia) Scarlet Fever Ear Infections (PE tubes) Sensory Losses

6 Other Ear Problems Sexual Molestation Eczema or Hives Sexually Transmitted Disease Electric or Chemical Shock Speech/Language Problems Encephalitis Spells( ) Epilepsy, Seizures, Fits Stroke Suicide Attempts/Thoughts Indicate if the child has undergone any of these Sunstroke/Heat Exhaustion Medical tests (place check and give age) Thyroid Disorder or Problem Trauma ( ) Electyoencephalogram (EEG) Tuberculosis Skull X-rays Tumor CT Scan Visual Problems MRI Scan Whooping Cough BEAM Study Evoked Potential OTHER MEDICAL PROBLEMS: Ophthalmologic (Vision) Audiological Evaluation Medication allergies Pediatrician s name and address: Current medications being taken: If the child has ever been treated with medication other than for colds and minor infections, please list medications below: MEDICATION AGE REASON PRESCRIBED Has your child ever suffered a head injury which caused confusion/loss of consciousness? Yes No FAMILY MEDICAL HISTORY Place a check next to any illness/condition, or problem experienced by any blood relatives. When you check an item, please note the member s relationship to the child. If any problems run in the family, please write them down at the end of the list: CONDITION RELATIONSHIP TO CHILD Alcoholism Antisocial (criminal) behavior Blood Disease Cancer Cerebral vascular accident (stroke) Dementia Drug addiction or drug problems Headaches (e.g., migraine) Heart disease or attack Hyperactivity Hypertension (high blood pressure) Learning Problems Lung Disease (e.g., asthma, emphysema) Manic-Depressive disorder

7 Mental Retardation Movement disorders Nervous or mental problems Pain problems (e.g., back pain) Schizophrenia Seaizures, epilepsy or convulsions Sexual/physical abuse Suicide or suicide attempt