2026 Confidential Parent Questionnaire

2026 Confidential Parent Questionnaire

(All information provided is strictly confidential and will not be provided to any other agency without your written consent.)
Child's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I. General Information
Please share any concerns or questions you have about your child’s development. This may include areas where you’ve noticed your child needs extra support, skills that seem to be emerging more slowly, or aspects of their communication, play, movement, or learning that you would like us to understand more deeply.:
When did you first notice these concerns:
List any diagnoses your child has and the professional who made the diagnosis
Has your child received any previous treatment for the above diagnosis/es?
If yes, please explain:
Is a second language spoken in the home:
If yes,
Please list other persons living in your home, their ages, and relationship to child
What do you hope to learn from this evaluation and what specific questions do you have or areas do you wish to address?
II. Developmental History
A. Prenatal
How was the health of the mother during this pregnancy?
Please check any conditions that applied to the mother during this pregnancy:
Did the mother take any medication or drugs during this pregnancy?
YES NO

If yes, what? Type a label
B. Peri-natal
Weight of Child at Birth: pounds, ounces
Duration of pregnancy:    weeks.
Were instruments used: YES    NO      If yes, what:
Was the delivery: Spontaneous    Induced   Cesarean    Breech
Was the baby given blood transfusions or exchanges at birth?YES    NO
Was the baby given oxygen? YES    NO
Were there any problems after birth? YES    NO
If yes, Feeding Problems Other Illness, Explain
Was baby released from hospital with the mother? YES    NO
If no, when?
III. Health History
Indicate any illnesses the child has had. Specify information age, date of occurrence, and medical treatment received:
Indicate any surgery your child has had. Specify date of surgery, where, duration of hospitalization, and attending physician:
Please list any medications the child is currently taking:
Please list any allergies including foods, medications, and environmental agents:
IV. Development
A. Motor Skills
At what age did your child:

Please indicate whether your child CAN or CANNOT do the following with respect to motor skills:

Rows	YES	NO	UNSURE	N/A
Throw a ball
Catch a ball
Kick a ball
Run
Jump with both feet
Go up and down stairs

Please describe any differences you noticed in your child’s motor development from other children at the same age:
Please describe any assistive equipment your child uses:
What movement activities does your child like?
What activities does your child avoid?
B. Sensory Skills
Does he/she seem overly sensitive to:

Other
Does he/she:

Other
Does your child react to certain textures, smells, tastes, or sounds? If yes, describe.
C. Fine Motor Skills
Does he/she struggle with the following:

Other
Which hand is used most often?
Do you feel your child’s hand skills are delayed? Please list the hand skills you feel are difficult for him/her to do:
D. Self-Care Skills

Please indicate whether your child CAN or CANNOT do the following with respect to eating:

Rows	YES	NO	UNSURE	N/A
Suck from bottle/straw
Hold and drink from cup with sipper top
Finger feed
Hold and scoop with a spoon
Stab with a fork
Use a knife to spread/cut
Feed self without help

Describe any help needed for feeding:

Please indicate if your child CAN or CANNOT do the following with respect to dressing:

Rows	YES	NO	UNSURE	N/A
Puts on/Removes shoes and socks
Puts on/Removes clothing
Tie Shoes
Buttons
Zips

Describe any help needed for dressing:

Please indicate if your child CAN or CANNOT do the following with respect to toileting:

Rows	YES	NO	UNSURE	N/A
Toilet trained
Completing intentional control of bowel movements and urination
Cleaning body
Transferring to and from toileting position
Caring for menstrual needs

Describe any assistance required for toileting:

Please indicate whether your child CAN or CANNOT do the following with respect to bath/shower:

Rows	YES	NO	UNSURE	N/A
Soaping
Rinsing
Drying body parts

Describe any assistance required for bathing:

Please indicate what child CAN or CANNOT do with respect to hygiene:

Rows	YES	NO	UNSURE	N/A
Washing, drying, combing, styling, brushing
Caring for nails
Applying deodorant
Brushing teeth

Describe any assistance required for general hygiene:
D. Psychological/Play Development

Does your child have difficulty:

Rows	YES	NO	UNSURE	N/A
Have difficulty paying attention
Have difficulty sticking to one activity for 3-4 minutes
Have difficulty switching tasks
Have rituals (doing the same thing in the same way each time)
Become easily frustrated
Have trantrums
Hit/Bite

Please share any behaviors or challenges your child is experiencing that you’d like support with, especially those that affect daily routines or participation:
Does he/she prefer to play with older children? Younger children? Alone?
What are your child’s favorite play activities toys, games etc.?
Does your child have unusual fears? Preoccupations?
Has he/she had any evaluations for behavioral or emotional difficulties? If so, by whom and when?
Please check any that apply to your child:

Other
Is the child/Does the child:

Other
V. Feeding History
Does or did your child have difficulty with any of the following:

Other
Is your child a picky eater:
If yes, explain. What food textures do they prefer or avoid:
VI. Speech-Language Development
What is/are his/her most frequent means of communication:

Other
How old was your child when he/she used his/her first meaningful word, other than “mama”/“dada”?    What was the word?
Does s/he have difficulty pronouncing any sounds? YES    NO
If so, which ones?
Can parents understand his speech? YES    NO
Relatives? YES    NO
Playmates? YES    NO
Teachers? YES    NO
Is your child easily frustrated when he/she is not understood? If so how does he/she express that frustration?
Is your child aware of his/her communication difficulties?
At what age did your child:
VII. Hearing/Vision
Hearing
Do you suspect any hearing difficulty?   Yes   No
Has your child’s hearing been tested?   Yes   No   If yes, When      Where?      Results?
Has your child been diagnosed with a hearing impairment?   Yes   No   If yes, by whom and when      Please describe hearing loss that has been diagnosed:
Do you think he hears your voice?   Yes   No   How do you know?
Does he know from which direction sounds come?     Yes   No
Does he hear better with one ear than the other?   Yes   No
How do you get the child’s attention when his back is turned away?
Can your child understand directions/and or conversation:   Yes   No   If “no”, what behaviors have you observed?
Has your child been diagnosed with an auditory processing disorder?   Yes   No
Vision
Do you suspect any vision difficulty?   Yes   No
Has your child been seen by an optometrist or ophthalmologist?   Yes   No
If yes, When      Where?
Results?
Any suspected vision problems, surgeries, or diagnoses ?   Yes   No
If yes, please describe:
Does the child wear glasses or corrective lenses?   Yes   No
VIII. Educational History
Name of school presently attending:
Grade or level:
Describe general progress and behavior in school:
Does your child have an IEP:
If yes, please upload below:

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Is your child currently receiving any specialized educational supports or additional learning services (such as special education, small-group instruction, tutoring, or academic interventions)?

Other
If so, please share where these services take place (school, private provider, community program, etc.), what areas they support (communication, literacy, executive functioning, motor skills, social-emotional learning, academic skills, etc.)?:
Does your child display preference for any learning style over another? Visual, auditory, both?
Does your child receive any therapies currently:
If yes, please describe and provide therapist names, etc.
Has your child received therapy in the past?
If yes, please upload any pertinent evaluations or therapy notes:

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IX. Additional Parent Comments
Please share anything that helps us better understand your child’s current needs, comfort, and overall well-being. Your insights ensure we provide care that aligns with your child’s strengths and supports their success across settings:
Completed by:
Relationship to Client:
Email
example@example.com
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

2026 Confidential Parent Questionnaire

I. General Information

II. Developmental History

A. Prenatal

B. Peri-natal

III. Health History

IV. Development

A. Motor Skills

B. Sensory Skills

C. Fine Motor Skills

D. Self-Care Skills

D. Psychological/Play Development

V. Feeding History

VI. Speech-Language Development

VII. Hearing/Vision

Hearing

Vision

VIII. Educational History

IX. Additional Parent Comments