NEUROPSYCHOLOGICAL EVALUATION SOCIAL AND DEVELOPMENTAL HISTORY Step 1 of 14 7% Child's Full Name:(Required) Gender:(Required) Male Female Nonbinary Transgender Date of Birth:(Required) School Attending: Current/Most Recent Grade: Parent Name: Age/DOB: Highest Level of Education: Employer: Current (most recent) Occupation: Address: Street Address City State / Province / Region ZIP / Postal Code Phone (cell, home, work):Email Address: Parent Name: Age/DOB: Highest Level of Education: Current (most recent) Occupation: Employer: Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone (cell, home, work) :Email Address: Legal Guardian Status (check one): 01 – Biological Parents 02 – Biological Mother 03 – Biological Father 04 – Adoptive Parents 05 – Adoptive Mother 06 – Adoptive Father 08 – Family & Children’s Svcs. 09 – Court (specify) 10 – Other (specify) Court (specify): Other (specify): Marital Status of Parents (check one): Married Single Married, living apart Joint custody Divorced (check custodial status) Sole custody (check which parent) Custodial Status: Joint custody Sole custody (check which parent) Which Parent: Mother Father Does child have visitation with non-custodial parent? Yes No Other Other (explain): List the name and ages of additional people currently living at your child’s residence or siblings/other family members significantly involved in their life: Name Add RemoveRelationship to Child Add RemoveAge and Education/Level Add RemovePrimary Language Add RemoveWhat is your child’s primary language? Are there other languages spoken in the home? Yes No Other languages: GENERAL:What are your hopes or vision for your child?What concerns do you have about or for your child?Briefly describe your child’s current difficulties:What would you like to learn from the evaluation? MEDICAL AND DEVELOPMENTAL HISTORY:Describe any complications, medications, or other concerns experienced during the pregnancy (e.g., diabetes, high blood pressure, toxemia, etc..):At the time of birth/delivery:Was the child full term? Yes No Duration of pregnancy: Cesarean Section? Yes No Birth weight: Please describe any complications with the birth, delivery, or after delivery:List any serious illness, injury, hospitalization, surgery, or traumatic event (e.g. diabetes, seizures, head injury asthma, allergies, etc.):Child’s age at time: Current Medical diagnoses (if any): Physician’s name(s): Diagnosis Date(s): Please attach any pertinent physician report or diagnostic statement. Drop files here or Select files Max. file size: 10 MB. Please list all currently prescribed medications: Medication: Add RemoveDosage: Add RemovePrescribing physician and date: Add RemoveVision Problems? Yes No Glasses? Yes No Contacts? Yes No Date of last vision exam: Results: Hearing problems: Yes No Age Detected Tubes in ear: Yes No Date: Hearing aids: Yes No Date: Cochlear implant: Yes No Date: Date of last hearing exam: Results of last hearing exam: Has the child ever been to a counselor, therapist, psychologist or psychiatrist? Yes No If yes, please explain: Has your child been evaluated before? Yes No Date(s) of Evaluation(s): Who evaluated them? Please attach a copy of the evaluation report. Drop files here or Select files Max. file size: 10 MB. Do you have a family history (biological parents, siblings, grandparents, aunts, uncles) of any of the following? Learning difficulties (reading, spelling, writing, math, organization) Speech or language difficulties (articulation, stuttering, organizing/recalling words, etc.) Emotional difficulties (depression, anxiety, mood swings, psychosis, etc.) Cognitive difficulties (may have been called mental retardation or mental handicap) Genetic medical conditions Abuse or domestic violence Substance abuse (drug or alcohol) If so, please describe: DEVELOPMENTAL INFORMATION:Behavior in INFANCY – During the first few years of life were any of the following present to a SIGNFICANT degree? Did not enjoy cuddling Was not easily calmed by being held or stroked Difficult to comfort Colicky Excessive irritability Frequent head banging Difficulty nursing Poor eye contact Did not turn towards caregivers Did not respond to name Did not respond to speech of caregivers Constantly into everything Please describe all checked itemsMilestone: Sat up without help 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Crawled 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Walked alone 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Walked up stairs 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Spoke in words 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Spoke first phrases 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Spoke in sentences 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Fully bladder trained 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Fully bowel trained 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Milestone: Stayed dry all night 0-3 Months 4-6 Months 7-12 Months 13-18 Months 19-24 Months 2-3 Years 3-4 Years Other Child’s Early Temperament: (Toddler through five years of age):Activity Level- How active has your child been from an early age?Distractibility – How well was your child able to maintain focus or concentration, or pay attention to task?Adaptability – How well was your child able to deal with transition, change or when denied his/her own way?Approach/Withdrawal – How well was your child able to respond to new things (i.e., new places, people, food, etc.)? Intensity – Weather happy/unhappy, how strong were your child’s feelings exhibited? Were others made aware of when your child was upset, angry, disappointed, etc.?Mood – What was your child’s basic mood? Did he/she exhibit frequent or rapid changed in moor or temperament?Regularity – How predictable was your child’s patterns of activity level, sleep, appetite, etc. ? Home Behavior How often is each of the following settings a problem for your child? While getting ready for school Rarely Sometimes Frequently When eating at the dinner table Rarely Sometimes Frequently When playing by him/herself Rarely Sometimes Frequently When playing with siblings/other children Rarely Sometimes Frequently When with babysitter or daycare Rarely Sometimes Frequently In public places (church, store) Rarely Sometimes Frequently When in the car Rarely Sometimes Frequently When told to do something he/she doesn’t want to do Rarely Sometimes Frequently During sit-down homework time Rarely Sometimes Frequently When watching TV or playing video games Rarely Sometimes Frequently How do you describe your child personality at home?How does your child get along with brothers/sisters?Which adult would child prefer to talk with about a problem?Who is the family member with whom your child feels closest?Who is primarily responsible for discipline at home? How do you and/or your partner deal with any behavioral problem at home? (spanking, talking, positive reinforcement, time-out, grounding, etc.)How does your child respond to discipline?List any responsibilities your child has at home: Does your child do these regularly? Yes No Does your child need frequent reminders? Yes No Indicate childs...Bed Time? Wake up time? Does child sleep well? Yes No How much time does your child typically spend on electronic media? Watching TV (hrs/day): Playing video/computer games (hrs/day): Other activities (hrs/day) Have any family members expressed concerns about your child’s behavior? Yes No Explain: ADAPTIVE BEHAVIOR Does your child have any difficulty or delay in the following areas? If so, please describe. Communication Skills Making or producing speech sounds Understanding language Using language to communicate Understanding social communications Reading/understanding body language and nonverbal communication Oral motor skillsChewing solid food Drinking from a cup Drinking through a straw Excessive drooling Swallowing problems Sensitivity to different textures of food/drink Sensitivity to different temperatures of food/drink Motor Skills Walking Running Jumping Climbing stairs Walking on uneven surfaces Balance Manipulating small objects with hands Using silverware or writing utensils Tying shoes, using zippers, buttons. Etc. Independent Living Skills Feeding self Dressing self Personal hygiene Toileting Bathing self Performing assigned chores Responses to sensory experiences:Does your child display any unusual or atypical behaviors, responses, or sensitivities in any of the following areas?Taste Smell Movement Tactile/touch/texture Visual Auditory/filtering Patterns of Emotional Adjustment:Do you consider any of the following to be a problem for your child at this time (check all that apply)? Fidgets, is easily distracted, has a hard time staying seated, has difficulty waiting for his/her turn Talks excessively, interrupts often, doesn’t listen Often loses things, very disorganized compared to others of his/her age Poor concentration Difficulty initiating task Difficulty completing tasks Difficulty following instructions Engages in impulsive behavior \(acts before thinking) Immature compared to peers Engages in physically dangerous activities Often argumentative with adults Often actively defiant to adult requests and rules Often deliberately does thing to annoy others Blames others for own mistakes Often angry or resentful Somatic complaints of not feeling well Excessive separation difficulties Easily frustrated Lies Steals Often depressed/irritable mood Low energy/fatigue Shy Feeling of worthlessness or low self-esteem Withdrawn Overly anxious or fearful Sleeping too little/insomnia Sleeping to much Difficulty making decisions Cries easily Temper tantrums Rapid mood changes/mood swings Suicidal thoughts Aggressive towards peers Aggressive towards audults Poor appetite Overeats Explosive temper with minimal provocation Odd fascinations Unrealistic worry about future events Substance abuse Other Please explain any checked items: Unusual or Atypical Behaviors:Does your child display any of the following behaviors (check all that apply)? Preoccupation with specific subjects, topics, or objects that is atypical in intensity or focus Eccentric forms of behavior Lack of awareness or sensitivity to the need or feelings of others Facial expression or emotional responses that are not appropriate to or consistent with the circumstances A need or desire to do things in a very specific way or order, or rituals that must be followed Mannerisms or odd ways of moving his/her body Self injury or physical aggression toward others Difficulty understanding jokes or humor Difficulty adjusting to new surroundings Difficulty adjusting to change in plans or routines Struggles to maintain age-appropriate eye-contact Please explain any checked items: SOCIAL SKILL INFORMATION:How does your child get along with adults at home?How does your child get along with brothers and sisters or other children in the home?How does your child get along with peers?Describe your child’s friendships:What are your child’s favorite activities?Behavioral and social strengths?Behavioral and social weaknesses? SCHOOL INFORMATION:List, in order of attendance, the schools your child has attended (for children 7 and younger, include preschools and daycare center attendance)School/Preschool/Daycare Add RemoveDates of attendance Add RemoveHas your child ever repeated a grade? Yes No If yes, what grade was repeated? What School? Describe your child’s strengths at school:What are your child’s weaknesses at school?Have there been any major changes in your child’s attitude towards school? Yes No If yes, please describe: Has your child been involved in any of the following (please check all that apply): Educational services from private entity (e.g., private tutor, Sylvan, Learning Rx, Lindamood Bell, etc.) Therapy services from private entity (e.g., speech, occupational/physical therapy, vision therapy, etc.) Counseling Department of Children’s Services Juvenile Court or probation Hospitalization Summer School Evaluation from private entity (e.g., psychological, academic/educational, mental health, behavioral, etc.) Other Early intervention program Educational services from private entityDates:For how long:Therapy services from private entityDates:For how long:CounselingDates:For how long:Department of Children’s ServicesDates:For how long:Juvenile Court or probationDates:For how long:HospitalizationDates:For how long:Summer SchoolDates:For how long:Evaluation from private entityDates:For how long:Other Early intervention programDates:For how long:If other, please list:Please explain items checked:Please attach any relevant reports. Drop files here or Select files Max. file size: 10 MB. Other information you believe may be relevant in the evaluation of your child: