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Basic Information
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Child's First Name:
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Child's Last Name:
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Child's Gender:
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Child's Birth Date:
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Child's Grade:
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Child's Name of Preschool (if applicable):
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Name of person completing this form:
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Relation to child
(mother, father, guardian, other):
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Address:
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City:
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State:
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ZIP:
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Phone:
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Alternate Phone:
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Email:
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Preferred Method of Contact:
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Emergency Contact (Email, Phone, etc):
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Who referred you to CReATE or how did you hear about us?
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Do you want us to have contact with your referral source?
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If yes, Name, phone number, and email of referral source:
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Briefly describe the reason for referral, your concerns, or a little about your child's current difficulties:
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Pregnancy/Developmental History:
Was your child adopted? If yes, please indicate at what age and any special circumstances
(e.g. foreign or domestic adoption, conditions of orphanage, suspected abuse or neglect, etc.):
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Were there any illnesses or complications with the mother while pregnant with this child?
If yes, please explain:
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Was the child born full-term? If no, how many weeks gestation and weight at birth?
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Describe any problems related to the child's birth:
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Describe any concerns or problems regarding infancy or early childhood development:
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How would you describe your child's overall rate of development? (delayed, Normal, Advanced):
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Please describe your child in regard to:
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Temperament?:
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Sleep patterns?:
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Eating patterns?:
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Social interactions?:
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Behavior?:
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Academic Information:
Do you have concerns about your child 's academic progress in preschool?
If yes, please describe briefly:
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Has your child/adolescent ever received special education services or
been evaluated by the school system or CDSA? (i.e. to determine eligibility for IEP, IFSP or special services)?
If yes, what was the outcome?
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Have you ever sought specialized tutoring services or other services privately such as speech-language therapy
or occupational therapy services for your child? If yes, please describe briefly:
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Has your child been previously diagnosed with any learning difficulties
(e.g. ADHD, sensory processing difficulties, speech-language delays). If yes, what diagnosis and by whom?
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Has your child been tested for mental health, developmental or learning concerns previously?
If yes, when was the testing done and by whom (i.e. school system, private evaluator, hospital)?
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Behavioral Concerns
Are you concerned about your child’s behavior at home or in school or both?
If yes, Please describe briefly:
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Briefly describe any behavioral concerns, including nchar10ing or aggressive behavior:
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Emotional Concerns
Are you concerned about your child’s emotional regulation? If yes, please describe briefly:
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Are you concerned about your child’s anxiety? If yes, please describe:
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Has your child been previously diagnosed with any emotional problems
(e.g. Depression, Anxiety, Social Phobia, Panic Disorder, etc.)? If yes, please describe:
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Describe any major traumatic events or changes in your child’s life (e.g. abuse, illness, death, difficult
moves, difficult transitions to new schools, etc.)
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Has your child ever been hospitalized for psychiatric/psychological reasons?
If yes, please describe circumstances, dates, and diagnoses:
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Has your child ever expressed suicidal ideation or engaged in any self-harm?
If yes, please describe circumstances and dates:
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Medical Concerns
Does your child have any chronic or recent medical concerns? (e.g. chronic ear infections when younger, PE tubes, asthma, allergies,
cerebral palsy, diabetes, food allergies, etc.) Please describe history and treatment:
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Has your child experienced any concussions or head injuries or had numerous visits to the ER?
If yes, please describe:
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Has your child had any surgeries? If yes, please describe:
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Is your child currently taking any medications? If so, please list and describe any side effects:
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Name of Primary Care Physician:
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Approximate date of last vision/hearing screening and indicate if results were normal or abnormal:
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Family Information
Does your child live with both parents? If no, briefly describe custody and living arrangements:
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Is any legal action currently underway in this family? If yes, please explain:
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If parents are divorce/separated, is the other parent aware that you are
seeking an evaluation for your child?:
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Father's Name and Occupation (optional):
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Mother's Name and Occupation (optional):
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Stepfather's Name and Occupation (optional):
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Stepmother's Name and Occupation (optional):
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Siblings (number of siblings, names and ages):
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Briefly describe any significant family information, such as parent-child conflict,
marital discord, or significant discord between family members:
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Has your child recently moved or changed schools? (If so, describe):
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Is there a family history of learning or mental health concerns
(e.g. ADHD, dyslexia, depression, OCD, etc)? If so, who?:
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Please list your child's strengths, hobbies, interests, achievements, or positive traits:
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