Child Developmental History

A. Identifications

1. Child’s full name:*

Child’s birthdate:*

Person completing this form:*

Today's Date:*

Parent 1

2. Full name:*

Birthdate:*

Phone:*

Address:*

Occupation:*

Work phone:*

Cell phone:*

Email:*

Highest level of education:*

Parent 2

2. Full name:

Birthdate:

Phone:

Address:

Occupation:

Work phone:

Cell phone:

Email:

Highest level of education:

4. Parents are currently:*
MarriedDivorcedSeparatedNever MarriedWidowed

Child’s custodian/guardian is:

5. Step-parent’s name, if applicable:

6. Other family members (please include ages):

Is there any known family history of learning, developmental, neurological, or psychiatric disorder? (please specify):

B. Identifications

Please fill in any information you have on the areas listed below.

1. Pregnancy and Delivery

Was the child premature?
NoYes

Prenatal medical illnesses and health care:

Weight and height at birth:

Any birth complications or problems?

2. The first few months of Life

Sleep patterns or problems:

Temperament & Personality as an infant (i.e., “easy”; “difficult to soothe”, etc):

3. Milestones: At what age did this child do each of these?

Sat without support:

Crawled:

Walked without holding on:

Age when child said first word understandable to a stranger:

Age when child said first sentence understandable to a stranger:

Any speech, hearing, or language difficulties?

C. Health

List all childhood illnesses, hospitalizations, allergies, head injuries, important accidents and injuries, surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions.

Condition, Age and Treated by Whom?

Condition, Age and Treated by Whom?

Condition, Age and Treated by Whom?

Condition, Age and Treated by Whom?

Name of Primary Care Clinician (i.e., pediatrician):*

Is the child currently prescribed any medications? (if so, please list name, dosage, and prescribing clinician):

D. Residences

Location(s) and date(s) lived:*

E. Schools

School (name, district, address, phone) and age at each:*

F. Concerns

Do you have concerns about your child and substance use, including the use of alcohol?
NoYes

If yes, elaborate:*

Do you have concerns about your child and self-harm, including thoughts of suicide?
NoYes

If yes, elaborate:*

Has your child been exposed to incidents of violence or other traumatic experiences, including verbal or physical aggression in the home?
NoYes

If yes, elaborate:*

G. What are your child’s strengths? Does he/she have any special skills or talents?

List hobbies, sports; recreational, musical, TV, and toy preferences; etc.:*

H. Other

Is there anything else I should know that doesn’t appear on this or other forms, but that is or might be important?

I. Choose Clinician Below

Choose Clinician:*
Dr. MoldoverDr. HebertDr. Benetti-McQuoid