Child Developmental History
Clinician
*
Adrianne Smith
Ali Depaul
Allison Driscoll
Alyssa Miralles
Amy Burrell
Anthony Richardson
Ashley Ness
Audra Etes
Berthania Boursiquot
Breanna Sansone
Carlie Dackson
Christina Moore
Daniel Resto
Danielle Casapulla
Deja Fulton
Dori Reix
Ebony Rainge
Elizabeth Gardner
Emily Nicefaro
Gina Rodican
Jackie Acampora
John Parise
Kaye Henry
Kristen Rogers
Kristin Caceres
Layla Cesar
Lisa Stevenson
Louisa Meresko
Marisa Rambush
Megan Purvis
Melissa Lester
Meredith Lall
Pam Feroleto
Peter Samenfink
Rebecca Kazlauskas
Sarah Yagovane
Shayla Richardson
Starr Radin
Stephanie Swantek
Stephen Bagoly
Tara Wilczynski
Teyonda Davis
Tierra Soto
Please Select the Clinician instructed by the Intake Department \Staff member
Client Name
*
First Name
Last Name
Client ID #:
*
Adverse Prenatal/Perinatal Factors (family, health, exposures, other):
*
Characterization of Infant/Toddler:
*
Preschool Experiences (Daycare, Nursery School, Lessons):
*
Any problems with:
*
Rows
Early
Within Normal Limits
Late
Sitting
Walking
Language/Speaking
Hearing/Visual
Toilet Training
*
Rows
Yes
No
Unsure
Labor/Delivery
Eating
Sleeping
Behavior/Trantrums
Colicy
Activity Level
Separation
Enuresis/Encopreseis
Illness (i.e. Ear Infection)
Explanation:
Submit
Should be Empty: