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