Parent Referral and Case History

Parent Referral and Case History

Information provided on this form will remain strictly confidential

Date Completed:______Person completing form:______

Child’s name (First)______(MI)______(Last)______

Age ______Grade______Teacher______

Birth date______/______/______

Sex Male Female

Is your child Medicaid eligible? Yes No If yes, Medicaid #______

Child’s primary language______Other languages spoken in home______

Name of Parent(s) or Guardian:

Mother______

Home Phone______Cell Phone ______

Address______

E-mail______

Employer______Occupation______

Work phone ______Highest Grade completed______

What is the best way to contact? ______

Father______

Home Phone______Cell Phone ______

Address______

E-mail______

Employer______Occupation______

Work Phone ______Highest Grade completed______

What is the best way to contact? ______

Other People living in home:

Name Age Relationship to child

______

Does this child have other parent(s)/stepparent(s)? No Yes

If yes, please provide the following information

Name ______Relationship to this child______

Home Phone______

Address______

Name ______Relationship to this child______

Home Phone______

Address______

Child Care

If primary caregivers work outside the home, please provide the following information.

Who cares for this child when caregivers are gone?______

How many hours per day is this child in a child-care setting?______

Family History

Is this child closer to one parent than the other? No Yes If yes, which?

Has this child ever experienced any parental separations, divorces, or death? No Yes

If yes, when?______How old was this child at the time?______

If parents are separated or divorced, who has custody of this child?______

How often does the other parent see this child?

Weekly or more often Once or twice a month Few times a year never

Was this child adopted? No Yes If yes, at what age?

Were any other children in the home adopted? No Yes

Pregnancy

Was the mother under a doctor’s care during the pregnancy? No Yes

Number of previous pregnancies/miscarriages: ______

Check any of the following complications that occurred during the pregnancy.

qDifficulty in conception

qMeasles/rashes

qExcessive swelling

qFlu

qToxemia

qExcessive vomiting

qEmotional problems

qAnemia

qAbnormal weight gain

qVaginal Bleeding

qHigh Blood pressure

qRH incompatibility

qPremature Labor

qExposure to chemicals or toxins

qMaternal injury

Describe: ______

qHospitalization during pregnancy:

Reason______

qX-rays during pregnancy:

What month? ______

Alcohol used during pregnancy:

qNone qOccasional qFrequent

qCigarettes used during pregnancy:

Frequency______

Drugs/medications used during pregnancy:

Type Frequency Prescription

______Yes No

Birth

At this child’s birth, what was the mother’s age? ______Father’s age? ______

Where was child born? ______

Length of pregnancy: ______weeks Birth weight: ______lbs ______oz

Length of labor ______hours Apgar score______

Child’s condition at birth______

Mother’s condition at birth______

Check any of the following complications that occurred during birth:

qForceps used qBreech birth qLabor induced qCaesarean delivery qPlacenta Previa

qOther delivery complications: Describe______

qIncubator: How long?

qJaundiced: Bilirubin lights No Yes If yes, how long?

qBreathing problems right after birth: Describe: ______

qSupplemental oxygen How long? ______

Was anesthesia used during delivery? No Yes If yes, what kind?______

Length of stay in hospital: Mother ______days Child ______days

Development

At what age did this child first do the following? Or Not yet?

______Turn over

______Sit alone

______Crawl

______Stand-alone

______Walk alone

______Walk up stairs

______Walk down stairs

______Show interest in sound

______Babbling

______Say 3 or more words

______Speak in a sentence

______Pull off clothing

______Dress self independently

______Finger feeding

______Use a spoon/fork

Was this child breast-fed? No Yes When weaned? ______

Was this child bottle-fed? No Yes When weaned? ______

Did this child use a pacifier? No Yes

suck on fingers or thumb? No Yes

When was this child toilet trained? Days: ______Nights: ______

Did bed-wetting occur after toilet training? No Yes If yes, until what age? ______

Did bed-soiling occur after toilet training? No Yes If yes, until what age? ______

Were there any medical reasons for bed-wetting or –soiling? No Yes

If yes, please describe______

Which hand does this child use for writing or drawing? Left Right Both

….Eating? Left Right Both

…..throwing a ball? Left Right Both

Medical History

Please check the illnesses this child has had and indicate age (year/month).

qMeasles

qRheumatic Fever

qGerman Measles

qDiphtheria

qMeningitis

qChicken Pox

qEncephalitis

qTuberculosis

qAnemia

qWhooping Cough

qFever above 104

qScarlet fever

qMumps

qHead injury: Describe______

qComa or loss of consciousness: Describe ______

Please describe other serious illnesses/operations/hospitalizations:

Illness/Operation/Hospitalization Age

Has this child ever been on long-term medication (more than 6 months)? No Yes

If yes, when? What kind?

Current Medications, dose (please list):

Please indicate if the child or family member exhibits or has a history of the following conditions by checking the appropriate column if true: (if not applicable because of child’s age please indicate n/a) If multiple options are listed, please circle the choice(s) that apply.

Condition/behavior / Child currently
Demonstrates condition or behavior / Child demonstrated behavior or condition in the past / Family member / If true, family member’s relationship to child
Example: plays piano / ü / ü / Grandmother
Sleep problems/staying asleep/getting to sleep
Eating disorder
Hearing problem/hearing aids/cochlear implant
Asthma
Allergies/Hay Fever
Autism/PDD/Asperger’s
Vision problems/glasses
Attention problems/ADD/ADHD
Diabetes
Tourette’s syndrome
Birth defect
Drug/alcohol abuse
Mental health problem: including depression, anxiety, psychosis, bipolar
Cognitive/Intellectual disability
Seizures/Epilepsy/abnormal EEG
Reading problems/dyslexia
Other learning disability
Speech-language problem
Head injury/head trauma/concussion
Sexual abuse/assault
Traumatic event
Frequent headaches
Physical disability
Cleft lip/palate
Muscular dystrophy
Fragile X
Tuberous Sclerosis
Obsessive-Compulsive Disorder

Comments:

Behavior/Temperament and Development

Please indicate whether this child exhibits any of these behaviors/problems: / A Current behavior or problem / A problem/behavior in the past
Temper tantrums
Difficulty learning to walk or crawl
Toe walking/odd gait when running
Difficulty learning to ride bike/difficulty with balance
Difficulty learning to catch a ball
Unclear speech/difficult to understand speech
Underweight/failure to thrive
Overweight
Colic/excessive crying
Eating disorder
Feeding/Swallowing problems/tube fed
Refusal to eat certain foods
Excessive vomiting/frequent diarrhea
Constipation
Stomach pain/GI problems
Ear Infections/Ear Tubes
Bangs head
Grinds teeth
Rocks back and forth, jumps, or flaps when excited/distressed
Sleep problems/staying asleep/getting to sleep
Overly Energetic/always “on the go”
Difficulty making/keeping friends
Odd or unusual behavior (please comment)
Compulsions/rituals
Intense interest in specific topic
Perseveration on topics/objects
Overly sensitive to smells/tastes/sounds/textures
Visual fascinations/looks at objects from an unusual angle
Lack of sensitivity to low level of pain
Makes inappropriate comments or demonstrates inappropriate behavior
Lacks empathy/understanding of other’s feelings
Needs excessive amount of reassurance
Difficulty expressing emotions or feelings
Difficulty with eye contact
Difficulty playing/interacting/conversing with others
Prefers to be alone/play alone
Exceptional memory for unusual facts/trivia
Overly upset by changes in routine/environment
Difficulty changing from one task to another
Unusual fears
Overreacts when faced with a problem
Giggles, laughs or cries easily
Currently / In the past
Perfectionistic
Asks the same question repeatedly
Aggressive toward others
Impulsive
Lacks self-control
Seems unhappy, sad or tearful
Hides feelings
Slow in completing tasks
Difficulty following directions
Difficulty remembering things
Difficulty organizing self or environment
Negative verbalizations about parents/teachers
Easily frustrated
Negative verbalizations about self
Withholds affection
Interrupts or Intrudes on others
Talks excessively

Comments:

What is the method of discipline used in the home?

Friendships and Social Skills:

Please indicate how this child relates to others:

Has problems relating to or playing with other children No Yes

If yes, please explain ______

Are there other children with whom this child regularly plays?______

Enjoys meeting new people No Yes

What role does this child take in peer group games (for example, leader, follower, observer, etc.)?______

What activities does this child enjoy?______

What are his/her favorite toys?______

Check the activities in which this child often participates in with the family:

qMovies qMeals qSports qGames qConversations qTrips

qVisits with Relatives qTelevision qChurch qOther: ______

Educational History

Early childhood

Please describe you child’s educational experiences

Where attended Dates of Enrollment Hours per week

Daycare______

Preschool______

Head start______

Older students Where attended Dates of Enrollment

Elementary ______

______

Middle School/Jr.Hi______

Senior High______

How many schools has your child attended? ______

Age started 1st grade:______

Has your child repeated any grades? No Yes If yes, when?______

Has your child ever been referred for speech therapy or special education evaluation? No Yes

Is your child absent frequently (missed more than 5 days last year?) No Yes

Were there any special circumstances? (please explain)______

What is the child’s attitude toward school?______

What are this child’s current after-school arrangements?______

What extra curricular activities is your child involved in?______

Parent Information

What are your primary concerns at this time regarding this child?

What do you feel are your child’s greatest strengths?

What would you like to learn from the evaluation?

Is there anything else you feel would be helpful to know about your child?

______

Other comments: