Child and Family Resource Clinic

Chanticleer Literacy Lab

Coastal Carolina University

Child/Adolescent Background Information

Child's Name:______Date of First Visit:______

LastFirstMI

Completed by: ______Relationship to Child:______

Child's Legal Guardian (Managing Conservator) if other than above: ______

Contact Information

Home Phone: ______(May call: yes__no__ May LeaveMessage: yes__ no__)

Cell Phone: ______(May call: yes__no__ May LeaveMessage: yes__ no__)

Work Phone: ______(May call: yes__no__ May LeaveMessage: yes__ no__)

Best Time and Place to call: ______

Contact e-mail address: ______

In case of emergency and you can not be reached at the above numbers contact:______

How were you referred to our clinic? (check those that apply): School personnel__ Family member__ Counselor/Psychologist/Psychiatrist__ Friend or Coworker__ Self__ Student in literacy class___ Other______

Child’s Information

Child's Address:______

StreetApt.CityStateZip

Child's Gender: Male__ Female__ Date of Birth______

Child's Ethnicity: Caucasian___ African American___ Hispanic/Latin___ Asian___

Native American___Bi-racial___ Other______

Child's primary language: English ___ Spanish ___ Other ___

Language spoken at home (parent’s language):______

Public School Information (if applicable)

Grade Level: ______Has your child ever been retained? No ___ Yes ___ If yes, what grade ______

Current School ______

Current Teacher(s): 1)______2)______3)______

Current School Counselor: ______

If your child receiving special education or other services? No ___ Yes ___ (explain) ______

______

______

Name of special education teacher: ______

Speech therapy:______

Has child been out of school for an extended amount of time or received homebound services? Explain ______

Other school information: ______

______

Home School Information (if applicable)

How many years homeschooled? ____ Who is providing the school supervision? ______

What program or curriculum is the child following? ______

How many hours of direct teaching does child receive a week? ______

How many children are in the home school at a time?______

Does child belong to a home school cooperative or group?______

Household Information

Child’s current household: Mother only ___ Father only ___ Natural parents ___ Natural Mother and Step-Father ___ Natural Father and Step-Mother ___ Blended family (both spouses with children) ___ Adoptive parents __ Grandparents___ Other Relatives __ Foster family __ Institution __ Other:______

List by Household your child’s current family, beginning with the oldest member and include the child:

Primary Household (anyone who currently lives with child)

How long in this current living situation: ______

Name AgeGenderRelationship to child (include step, half, etc.)

______

______

______

______

______

______

Second Household (non-custodial or extended family - if applicable)

Name AgeGenderRelationship to child (include step, half, etc.)

______

______

______

______

______

Child’s Health

Please indicate any physical problems or concerns that may impact attention, behavior, or limit activities:

Asthma_____Seizures____ Allergies____(Please list)______

Other physical problems: ______

Any medications that may be needed during the session: (epi pen, inhaler, prescriptions)______

Emotional health:

Please indicate any emotional problems or concerns that may impact attention, behavior, or limit activities:

ADD____ ADHD____ Anxiety____Conduct disorder ____ Extreme fears or phobias_____OCD___

Other health factors that may impact learning:

Chronic illness_____Developmental delays_____ Eating disorder_____ Major Illnesses_____

Sleep problems_____ Surgeries_____ Hospitalizations______Extended time out of school_____

Getting to know your child

Technology: Does child use:

Computer____ iPad____ personal cell phone___ laptop___ Playstation___ Wii_____ Gameboy___

Other______

Does child use iPad in school?______Hours a day on the computer: Weekday:_____ Weekend:____

About how many hours a week does child watch TV? ______

Reading

Reading in the home:

Do parents / guardians read for pleasure?______Does child see parents/guardians reading?______

Is there a library of books or reading materials that child sees being read from?______

Are magazines and newspapers read in the home?______Are there regular trips to the library? _____

Reading History:

Under age 5:

Did child enjoy being read to when young?______

How often was child read to?______

Did child like to hold books and turn pages?______

At what age did child start to connect words in books with pictures in books?______

What were child’s favorite books? ______

Currently:

What is the child’s attitude toward reading?______

Does child currently read for fun? What books? ______

Does child read on grade level? ______What is child’s current reading level?______

What problems does child have with reading?

Ability to Read_____ Attitude toward reading_____ Comprehension____ Learning disability____ Low grades____ Sounding out words____ Reading in subject areas (science, history)______

Special School Placements for Reading

Reading Recovery_____ Reading Intervention Programs/Burst/Passport______

Other (explain)______

Writing

Writing in the home:

Do parents / guardians write for pleasure?______Does child see parents/guardians writing?______

Are there materials for writing (paper, computer, crayons, pencils, markers) in the home?______

Do parents/guardians involve the child in writing at home (calendar, stories, cards/letters, to-do/grocery lists)? ______

History:

Under age 5:

Does child like to color or draw? ______

Does child hold pencil and pen correctly? ______

Can child write letters and numbers? (Do not need to be in order) ______

Currently:

What is child’s attitude toward writing? ______

Does your child write at home for enjoyment? (Journals/ diary, stories, letters, poems) Explain:

______

What problems does your child have with writing?

Low grades_____ spelling _____ attitude toward writing _____ writing complete sentences _____

Clearly expressing self _____ Other: ______

Use the back of this form to explain any other concerns or issues that may impact child’s reading/w ability or attitude.

Revised 9/10/13 1