Background Information
Child's Name
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Child's Date of Birth
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Month
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Day
Year
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Child's Grade
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Child's School
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Contact Information
Marital Status of Parents
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Single
Married
Divorced
Widowed
Other
If divorced, who is the legal guardian and what is the current custody arrangement? (Please bring a copy of the custody paperwork with you to the appointment)
Parent 1 Name, Address, Phone Number
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Parent 2 Name, Address, Phone Number
Please list the names, addresses, and phone numbers of any additional parental figures (i.e., step-parents, legal guardians, etc.)
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Referral Information
Who referred you to Dr. Lindsey Schriefer?
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What are your reasons/concerns for requesting an evaluation for your child? If possible, list any specific questions for which answers are sought.
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Household Information
List the names, ages/grades, and occupation of all people currently living in your household.
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Please describe any additional family circumstances including adoptions, previous marriages, divorces, remarriages, custody arrangements, living arrangements, and deaths in the immediate family. Include any dates as applicable.
Language(s) spoken in the home if not English
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Medical/Developmental History
Describe any complications that occurred during pregnancy, labor, or delivery.
What was your child's birth weight?
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How long after birth before your child came home?
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Describe your child’s temperament during the first 6 months (i.e., sleep patterns, colic, eating patterns, etc.).
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When did your child meet the following developmental milestones?
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Rows
Within Normal Limits
Early
Delayed
Sitting unsupported
Walking alone
Using single words
Using two or more words together
Please list any medical incidents (i.e., frequent ear infections, surgeries/operations, injuries). Include age of child and severity of occurrence. Please pay special attention to head injuries, any loss of consciousness, convulsing, or very high fever. Also include the results of any special medical tests administered (i.e., EEG, CAT scan, MRI).
Does/did anyone in your immediate family or a close relative have any of the following?
Nervous tics
Seizures/Epilepsy
Emotional problems
Hyperactivity
Learning problems
Language problems
Intellectual Disability
Similar problems to child
Please list any diseases that run in the family.
List all CURRENT medications (name, dosage, reason for taking, or NONE)
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When was your child’s last vision evaluation/screening? (month/year)
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What were the results?
Please Select
Normal
Nearsighted
Farsighted
Glasses/Contacts required
Further evaluation necessary
Other
When was your child’s last hearing evaluation/screening? (month/year)
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What were the results?
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Please Select
Normal
Hearing loss
Further evaluation necessary
Other
If your child has completed a previous psychological or neurological evaluation, list the date of the evaluation and who completed the evaluation. Please bring a copy of the written report with you to your appointment.
If your child has ever been hospitalized in a psychiatric facility, please list the name of location, dates of hospitalization, and reason for admission.
If your child has ever participated in psychotherapy, please list the name(s) of the provider(s), dates of service, and reason for service.
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Personality and Behavior
Please list your child’s personality characteristics, both positive and negative.
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Please note any particular behavioral concerns you have. (i.e., eating habits, sleeping patterns, level of activity, sibling relationships, peer relationships, moodiness, attention difficulties, destructiveness, unusual habits, fears, tenseness, etc.)
How do you currently discipline your child?
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Who disciplines?
Do parents agree on how to discipline?
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Please Select
Yes
No
Sometimes
How does your child respond when disciplined? (i.e., compliant, with anger, tears, indifference, remorse, etc.)
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Academic History
List all previous schools your child has attended, with grades and dates (include nursery and preschools).
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Describe any learning/behavioral/social difficulties your child is experiencing at school.
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Please list dates and services received for all of the following that apply:
If your child attends a private school, do they participate in any specialized programs through the school for learning support? If yes, please describe the program and indicate dates/grades participated.
If your child has ever repeated a grade, please indicate what grade(s) and the reason for repeating.
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Additional Comments
Please list any additional comments you have for Dr. Schriefer.
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