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Basic Information

Physical History

Did your child have any delays in reaching developmental milestones? Please estimate when your child gained these skills.

Note: If your child has been previously evaluated, please provide a copy of the report

Family History

The name of the child's biological parents:

Who does your child currently live with?

Who are significant people in your child’s life that do NOT live with him/her?

Education History

Psychological History

Has your child ever had difficulty with the following: (If so, please specify when)


Over the last two weeks, how often have you noticed your child may have been bothered by any of the following problems?

Not at all Several
days		 More than
1/2 the days		 Nearly
every day
Little interest or pleasure in doing things
Feeling down or hopeless or sad
Feeling tired or having little energy
Poor appetite or overeating
Difficulty concentrating
Feeling irritable
Poor sleeping or excessive sleeping


Has there ever been a time when your child was not his/her normal self and..

Yes No
They were so hyper they didn't appear themselves?
They felt so good it led to getting in trouble?
They slept less than usual but didn't seem to need it?
They had more energy and completed more activities than usual?
They were much more irritable than usual?
They were much more social than usual? For example, calling friends in the middle of the night; chatting with strangers
They engaged in risky behavior?
They showed hypersexual behavior?


Please answer the questions below using the option on the right that best describes what you may have noticed in your child over the past six months.

Never Rarely Sometimes Often Always
How often does s/he have difficulty staying organized?
How often does s/he have problems remembering things?
How often does s/he fidget or squirm when required to stay seated?
How often does s/he make careless mistakes?
How often does s/he have difficulty paying attention during boring or repetitive tasks?
How often does s/he misplace items?
How often is s/he distracted?
How often does s/he interrupt others who are talking?
How often does s/he have trouble unwinding after an activity or day?
How often does s/he have trouble waiting his/her turn?
How often does s/he appear to "space out"?

I understand that it is important to provide accurate information in order to tailor treatment and assessment to meet my child’s needs. This information is correct as I have described it.

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