Form filled out by
Please specify relation to child
Does the child have any illness or disability (either physical or mental)?
What concerns you most about the child?
Please describe the best things about the child
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.)
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
Fears certain animals, situations or places other than school
Feelings are easily hurt
Gets hurt a lot, accident-prone
Gets in many fights
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