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Parent Input & Developmental History Form
From Psychologist
Student Name:
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Date of Birth:
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Grade:
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Current Teacher:
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Today's Date:
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Parent/Guardian Completing Form:
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Relationship to Student:
*
Mother
Father
Relative
Legal Guardian
Sibling
Best Phone Number to be reached at:
*
Email:
*
If your child attended preschool, please list the years and places he/she attended:
Please list previous school your child has attended and when he/she attended:
What are your child's strengths?
What are your child's needs or weaknesses?
What suggestions do you have for your child's educational program?
Please list any additional information regarding your child's academic, emotional, or medical needs that you feel will assist the team with your child's evaluation including speech and language (reading, comprehending spoken language, articulation, fluency, voice).
Has your child had any evaluations that the school may be aware of? Check all that may apply:
Educational
Psychological
Medical
Speech
Other
None
Please provide any additional information regarding any above mentioned evaluations (dates, evaluators, etc).
Please upload any electronically saved evaluations or other relevant documentation.
Upload a File
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What is the primary language spoken at home?
Who currently lives in the home with the student? (Parents, siblings, grandparents, extended family, guardian, etc)
Describe any serious health problems mother experienced during pregnancy and/or labor:
Birth Weight:
Describe any difficulties your child had in learning to eat sleep, sit, walk, and talk:
Describe briefly any traumatic events that your child has experienced: (For example: death of a close relative, divorce, family crisis, etc.)
Please indicate any delays in the following developmental milestones:
Walking
Use single words (e.g., no, mom, dad
Combine words (e.g., me go, daddy shoe)
Toilet Training
Other
If any of the above items were checked, please provide additional details below:
Please provide the approximate age below of any illness or problems your child has had:
Physical Defect
Eye Problems
Operations
Temperature above 104 (Fever)
Frequent Colds
Speech Problems
Headaches
Diabetes
Allergies
Asthma
Epilepsy
Seizures
Serious accident/injury/illness
Frequent sore throats
Dietary problems
Heart Disease
Vision Problems
Other
Please describe any of the problems indicated above:
Has your child ever been hospitalized?
Yes (Please describe below)
No
Details of hospitalization?
Is your child currently under medical treatment or taking medications?
Yes (Please describe below)
No
Details of medications?
Describe any family history of educational, medical, behavioral or psychological impairment?
Is your child's vision normal?
Yes
No
Is your child's hearing normal?
Yes
No
Is your child currently in therapy?
Yes
No
Has your child been in therapy?
Yes (Please describe below)
No
If yes, please list type of therapy, frequency of sessions , and the name of the provider:
Please rate your child's general health:
Excellent
Good
Fair
Poor
Please comment on any behaviors that particularly concern you:
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Should be Empty: