Child Developmental History Form

GENERAL INFORMATION

Biological father

Biological mother

Guardian

Please list all people in child’s immediate family

Please list all other non- family members who live in household

Please List all locations (city, state) that your child has lived

(such as new marriages, deaths, births, address changes, family separation/divorce, parent dating, money problems, etc.)

What do you feel are your child’s...

HEALTH AND DEVELOPMENT

Please check the conditions below that describe the health of the child and mother during...

Mother’s Pregnancy

Child’s Delivery

Child’s Condition at Birth

Has your child had any of the following?

Is there a family history of the following?

Please indicate the age or age range when your child performed the following milestones

BEHAVIOR: if applicable answer age related questions

Child’s Early Temperament: (Toddler through five years of age)

Problems include: doesn’t follow directions/rules, needs reminders, argues/fights, whines/cries, fidgets, etc.

EDUCATIONAL HISTORY

Below please list school attended and describe your child’s academic and behavioral performance

ADDITIONAL SUPPORTS

Does receive or has your child received any additional therapy supports please list