Family Assessment
Child's Name
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First Name
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Child's Date of Birth
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1. What are your concerns about your child’s development?
2. Have other people (for example, babysitters,clinic personnel, spouse or relative) expressed those same concerns or any others about your child?
3. What people or groups have served as sources of support for you in the past 3-6 months?
4. Aside from the people you mention in #3, what other strengths do you or your family have that may enhance your child’s development (for example: financial resources, quality child care, professional support, personal experience with children with special needs)?
5. Do you feel you have adequate information about your child’s development or any difficulties he/she is having? If not, what would you like to know more about?
6. What are your longer-term goals for your child? What aspirations do you have for his or her future?
7. Are there aspects of your family’s lifestyle that should be considered when setting up services for your child? (Examples: Are other children home during the day? Do sessions need to be set up around parent’s work hours or somewhere other than in the home?)
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First Name
Last Name
Title
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Signature
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Date
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