Child questionnaire

Person completing questionnaire *

Relationship to Child *

Who reffered you to Weaver Center at this time? *

Does child have any school behavior problems? Please describe *

Does child have any school studies problems (besides chief problem?) Please describe *

Please describe child's weaknesses (other than chief problem) *

Parent Marital Status/History: *

If parent are separated or divorced, who has legal custody and describe physical custody arrangements: *

If family is reblended, please describe if relationships that are biological (note if biological - step) *

Whom does child live with at present time? (Include parents, brothers, sisters, grandparents, friends, etc.) *

What is the primary language spoken at home? *

Is Child/Family fluent in other languages? *

What is father's education? *

What is father's occupation? *

Please list relatives who have (or had) school problems: (*Family members include: biological parents, siblings, grandparents, aunts, uncles. Please include whether maternal or paternal)

Relatives*
Name: Maternal side

School/Learning Difficulties
(language, reading, writing, spelling, mathematics, foreign languages, etc.)

Relatives*
Name: Paternal side

School/Learning Difficulties
(language, reading, writing, spelling, mathematics, foreign languages, etc.)

Please list biological relatives with behavior problems

Relatives*
Name: Paternal side

Social/Emotional or Behavioral Difficulties
(overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)

Relatives*
Name: Paternal side

Social/Emotional or Behavioral Difficulties
(overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)

Has any relative* suffered from seizures, neurological disease or disorder? If so, please identify, diagnosis, treatment, and relationship *

Was child full term (was he/she born at expected time)? *

Weeks premature? *

Any complications? Explain *

Age of mother at delivery? *

Age of father at delivery? *

Seizures/convultions *

At what age? *

Were seizures associated with high fever? *

Has child had any serious illnesses? If so, what? *

When? *

How long? *

Has child ever been hospitalized? If so, why? *

When? *

How long? *

Has child ever had any operations? If so, what? *

When? *

Does child have any allergies? If so, to what? *

Treatment *

Has child had any head injuries? *

Circumstances *

When? *

Was child unconscious? If so, how long? *

Was child dizzy? *

Did child have headaches? *

Treatment, if any *

Does child have abdominal pains/vomiting? If so, how often? *

When does this occur? *

How is this treated? *

How often does child have headaches? *

When does this occur? *

How is this treated? *

Does child have vision problems? (Please specify) *

Approximate date of last examination *

Does child have hearing problems? (Please specify) *

Approximate date of last examination *

Does child have a history of frequent ear infections? *

How often? *

When? *

Treatment *

Does child have any sleep problems? (Please describe) *

Does child have any eating problems? (Please describe) *

Has CHIEF PROBLEM (see top) been treated medically in the past? *

Describe medication *

What changes, if any, did you notice? *

List the medications child currently takes: *

When medication started: *

Dosage *

Prescribing physician's name, address and phone number: *

As an infant, was child fussy? *

Over-sleepy/difficult to rouse? *

Did child respond to cuddling? *

Compared to other children, did child have problems learning:

To understand language? Please describe *

To talk? Please describe *

Gross motor skills (walking, hopping, riding bicycle, etc.)? Please describe *

Fine motor skills (fastening buttons, zippers, tying shoelaces, drawing, etc.)? Please describe *

Early school-related skills (naming colors, saying alphabet, rcognizing coins, etc.)? Please describe *

To play/socialize with other children? Please describe *

To build with blocks, play with puzzles, draw pictures? Please describe *

Does/did child have difficulty in leaving parents? At what age? Please describe *

Does/did child have toilet training difficulties? (For day? For night?) Please describe *

At what age did child show a clear hand preference? *

Which hand was preferred? *

Does child play with: *

older children younger children same age children

Does child have opportunity to play with children the same age? *

Has child ever had psychotherapy or counseling? *

When? *

With whom? *

How often? *

How long? *

Was it useful? Please describe *

May we contact therapist/counselor? *

Please rank your child's self-esteem (self-confidence) in the following areas (1=low; 5=high):

Have there been any major changes in these areas? When? Please describe *

Has child been evaluated by Public School? *

When (list each time)? *

Have there been any prior private (outside school) evaluations? *

When? *

Where? *

Has child ever repeated a grade? *

What grade? *

What schooling (if any) did this child have before first grade? Please specify *

In what grade did school problems become noticeable? *

Does/did child have an Individual Educational Plan? *

If yes, list years/grades it was for *

Does/did child have an accomodation plan (504 plan)? *

If yes, list years/grades it was for *

What specific educational interventions have been made in the past? *

Type(s) of specialist(s) *

How many times per week does child receive special education? *

What types? *

Has child had change of school or program? If so, please describe *

How many schools has child attended? *

Please list (include grade) *

Who is appropriate contact person for details of child's schoolwork? *

May the clinician call this person to ask about schoolwork, etc.? *

May we send our school questionnaire? *

Are there other school personnel whom we should contact? If so, please specify *

Are there any other professionals, outside of school, working with your child (e.g. TUtors, coaches, therapist, etc.)?

SIgnature *

Max file size: 20MB

Full name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Date *

Child questionnaire

Hours

Telephone

Email