General Information

Form filled out by

Relation to the child

Please specify relation to child

Does the child have any illness or disability (either physical or mental)?

Please describe

What concerns you most about the child?

Please describe the best things about the child

Language Development

Was the child born earlier than the usual 9 months after conception?

How many weeks early?

How much did the child weigh at birth? (provide information in pounds, ounces or grams)

How many ear infections did the child have before the age 24 months?

Is any language besides English spoken in the child's home?

specify the languages

Has anyone in the child's family been slow in learning to talk?

please list their relationship to the child (i.e brother, father)

Are you worried about the child's language development?

If yes, why?

Does the child spontaneously say words in any language (not just imitates or understands words)?

Does the child combine 2 or more words into phrases? (i.e "more cookie," "car bye-bye")

Please print 5 of the child's longest and best phrases or sentences. (For each phrase that is not in english, print the name of the language.)

General Behavior

Acts too young for his/ her age

Afraid to try new things

Avoids looking others in the eye

Trouble concentrating or can't pay attention for a longer time

Can't stand waiting; wants everything now

Can't sit still, restless or hyperactive

Clings to adults or too dependent

Constantly seeks help

Constipated, doesn't move bowels (not when sick)

Cries a lot

Cruel to animals


Doesn't want to sleep alone

Doesn't answer when people talk to him/ her

Disturbed by any change in routine

Destroys his/ her or others things on purpose

Doesn't eat well

Don't get along with other kids

Doesn't feel any guilt after misbehaving

Easily jealous

Fears certain animals, situations or places other than school

Feelings are easily hurt

Gets hurt a lot, accident-prone

Gets in many fights

Hits others

Angry moods

Holds his/ her breath

Looks unhappy without good reason

Nervous movements or twitching

Nightmares or Night terrors



Shows panic for no good reason

Painful bowel movements (without medical cause)

Picks nose, skin, or other parts of body

Poorly coordinated or clumsy

Plays with own sex parts too much

Screams a lot

Selfish or won't share

Shows little affection toward people

Too shy or timid

Sleeps less than most kids during day and/ or night

Stubborn, sullen, or irritable

Sudden changes in mood or feelings

Too fearful or anxious


Wakes up often at night

Wanders away

Others that were not mentioned


Define behavior

Rate behavior

Name & Signature of Parent/Caregiver
Name & Signature of Attending Physician