Developmental Form (Ages 0-5)

Please complete the following information so that we can better understand your concerns and the reasons you are seeking psychological or psychoeducational testing. This will help us determine the type of evaluation needed. Some questions may not apply and it is fine to just answer the question "No" or enter NA for " Not Applicable." The information in this form is guaranteed to be kept confidential and secure. Please remember to click "Submit" when you have finished.
 
    Basic Information
  Child's First Name: *
Child's Last Name: *
Child's Gender: *
Child's Birth Date: *
Child's Grade: *
Child's Name of Preschool (if applicable):
Name of person completing this form: *
Relation to child
(mother, father, guardian, other):
*
Address: *
City: *
State: *  
ZIP: *
Phone: *
Alternate Phone:
Email: *
Preferred Method of Contact: *
Emergency Contact (Email, Phone, etc): *
Who referred you to CReATE or how did you hear about us? *
Do you want us to have contact with your referral source? *
If yes, Name, phone number, and email of referral source:
Referral Name:
Referral Phone:
Referral Email:
Briefly describe the reason for referral, your concerns, or a little about your child's current difficulties:

    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.):
Were there any illnesses or complications with the mother while pregnant with this child? If yes, please explain:
Was the child born full-term? If no, how many weeks gestation and weight at birth?
Describe any problems related to the child's birth:
Describe any concerns or problems regarding infancy or early childhood development:
How would you describe your child's overall rate of development? (delayed, Normal, Advanced):
Please describe your child in regard to:
Temperament?:
Sleep patterns?:
Eating patterns?:
Social interactions?:
Behavior?:

    Academic Information:
Do you have concerns about your child 's academic progress in preschool? If yes, please describe briefly:
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?
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:
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?
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)?

    Behavioral Concerns
Are you concerned about your child’s behavior at home or in school or both? If yes, Please describe briefly:
Briefly describe any behavioral concerns, including biting or aggressive behavior:

    Emotional Concerns
Are you concerned about your child’s emotional regulation? If yes, please describe briefly:
Are you concerned about your child’s anxiety? If yes, please describe:
Has your child been previously diagnosed with any emotional problems (e.g. Depression, Anxiety, Social Phobia, Panic Disorder, etc.)? If yes, please describe:
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.)
Has your child ever been hospitalized for psychiatric/psychological reasons? If yes, please describe circumstances, dates, and diagnoses:
Has your child ever expressed suicidal ideation or engaged in any self-harm? If yes, please describe circumstances and dates:

    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:
Has your child experienced any concussions or head injuries or had numerous visits to the ER? If yes, please describe:
Has your child had any surgeries? If yes, please describe:
Is your child currently taking any medications? If so, please list and describe any side effects:
Name of Primary Care Physician:
Approximate date of last vision/hearing screening and indicate if results were normal or abnormal:

     Treatment History
Please describe any prior or current treatments, interventions, or therapies (outpatient therapy, psychiatric monitoring, medication, school-based interventions, etc.):
Name of Psychiatrist or Developmental Pediatrician, or Therapist (if applicable):

    Family Information
Does your child live with both parents? If no, briefly describe custody and living arrangements:
Is any legal action currently underway in this family? If yes, please explain:
If parents are divorce/separated, is the other parent aware that you are seeking an evaluation for your child?:
Father's Name and Occupation (optional):
Mother's Name and Occupation (optional):
Stepfather's Name and Occupation (optional):
Stepmother's Name and Occupation (optional):
Siblings (number of siblings, names and ages):
Briefly describe any significant family information, such as parent-child conflict, marital discord, or significant discord between family members:
Has your child recently moved or changed schools? (If so, describe):
Is there a family history of learning or mental health concerns (e.g. ADHD, dyslexia, depression, OCD, etc)? If so, who?:
Please list your child's strengths, hobbies, interests, achievements, or positive traits:

Please scan through the behaviors or concerns listed below and indicate if you have noticed that specific problem for your child. Please check all that apply.

Developmental: Please scan through the behaviors or concerns listed below and indicate if you have noticed that specific difficulty with your child. Please check all that apply.

Expressive language delayed:
No babbling by 9 months No single words by one year
No phrase speech by 18 months Only a few words by age 2
Repeated or echoed phrases without communicative intent (echolalia) Articulation poor or very difficult for others to understand
Initial language delayed but then progressed rapidly by age 3.5    

Receptive language delayed:
Did not respond to simple requests (e.g. "Come here") by 1 year Did not wave "bye bye" or clap hands by 1 year
Did not attempt to communicate by pointing by 14 months Did not understand simple words (e.g. "ball", "snack") by 18 months
Did not understand simple commands (e.g. "Get your shoes") by age 2 Did not use gestures or pointing to communicate
Did not look at people when they were talking Poor eye contact in general

Motor skills:
Did not sit up independently by 9 months Did not crawl or move around freely by 1 year
Did not walk alone by 18 months Walked on tip toes past age 2
Unusual posturing or hand movements Resisted coloring or drawing in preschool
Did not learn to tie shoes by age 5-6 Did not learn to ride a bike by age 5-6
Clumsy, awkward when running/jumping    

Social/Emotional:
No social smile by 6 months Not cuddly as an infant
Had colic or fussy as baby Did not respond to name by 9 months
Did not look at people when they talked to him/her by 1 year Did not enjoy simple games such as peek-a-boo or pat-a-cake by 1 year
Did not engage in imaginative play by age 3 Did not engage in cooperative imaginary play with peers by age 3-4
Lined up toys or played with parts of toys (e.g. spinning wheels) Preferred to play by self
Preferred to play with younger children Severe tantrums out of proportion for developmental age
Difficulty self-soothing    

Behavior:
Impulsive Very physically active for age
Ran about or climbed in situations where that was inappropriate Hard time sitting still for long
Could not sit through a meal by age 4 Concerns about behavior in preschool
Engaged in biting behavior in preschool Difficulty following directions
More defiant than typical for preschool years Morning, afternoon, bedtime routines difficult
Difficulty with sleep initiation Difficulty with early morning awakening
Night terrors Sleep walking

Adaptive Behavior:
Did not drink from cup by 12 months Did not feed self by 18 months
Could not dress self by age 4 Not potty trained by age 3 during day
Bed wetting at night past age 4    
 
*You will have a chance to elaborate on any of the above checked items when you talk with the psychologist.
However, if you want to briefly explain any items, you can do so here:



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