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NEUROPSYCHOLOGICAL EVALUATION SOCIAL AND DEVELOPMENTAL HISTORY

Step 1 of 14

7%
Gender:(Required)

Address:

Address:
Legal Guardian Status (check one):
Marital Status of Parents (check one):
Custodial Status:
Which Parent:
Does child have visitation with non-custodial parent?

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
Relationship to Child
Age and Education/Level
Primary Language
Are there other languages spoken in the home?

GENERAL:

MEDICAL AND DEVELOPMENTAL HISTORY:

At the time of birth/delivery:

Was the child full term?
Cesarean Section?
Drop files here or
Max. file size: 10 MB.

    Please list all currently prescribed medications:

    Medication:
    Dosage:
    Prescribing physician and date:

    Vision Problems?
    Glasses?
    Contacts?

    Hearing problems:
    Tubes in ear:
    Hearing aids:
    Cochlear implant:

    Has the child ever been to a counselor, therapist, psychologist or psychiatrist?
    Has your child been evaluated before?
    Drop files here or
    Max. file size: 10 MB.

      Do you have a family history (biological parents, siblings, grandparents, aunts, uncles) of any of the following?

      DEVELOPMENTAL INFORMATION:

      Behavior in INFANCY – During the first few years of life were any of the following present to a SIGNFICANT degree?
      Milestone: Sat up without help
      Milestone: Crawled
      Milestone: Walked alone
      Milestone: Walked up stairs
      Milestone: Spoke in words
      Milestone: Spoke first phrases
      Milestone: Spoke in sentences
      Milestone: Fully bladder trained
      Milestone: Fully bowel trained
      Milestone: Stayed dry all night

      Child’s Early Temperament: (Toddler through five years of age):

      Home Behavior

      How often is each of the following settings a problem for your child?

      While getting ready for school
      When eating at the dinner table
      When playing by him/herself
      When playing with siblings/other children
      When with babysitter or daycare
      In public places (church, store)
      When in the car
      When told to do something he/she doesn’t want to do
      During sit-down homework time
      When watching TV or playing video games

      Does your child do these regularly?
      Does your child need frequent reminders?

      Indicate childs...

      Does child sleep well?

      Have any family members expressed concerns about your child’s behavior?

      ADAPTIVE BEHAVIOR

      Does your child have any difficulty or delay in the following areas? If so, please describe.

      Communication Skills

      Oral motor skills

      Motor Skills

      Independent Living Skills

      Responses to sensory experiences:

      Does your child display any unusual or atypical behaviors, responses, or sensitivities in any of the following areas?

      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)?

      Unusual or Atypical Behaviors:

      Does your child display any of the following behaviors (check all that apply)?

      SOCIAL SKILL INFORMATION:

      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
      Dates of attendance
      Has your child ever repeated a grade?
      Have there been any major changes in your child’s attitude towards school?
      Has your child been involved in any of the following (please check all that apply):
      Educational services from private entity
      Dates:
      For how long:
      Therapy services from private entity
      Dates:
      For how long:
      Counseling
      Dates:
      For how long:
      Department of Children’s Services
      Dates:
      For how long:
      Juvenile Court or probation
      Dates:
      For how long:
      Hospitalization
      Dates:
      For how long:
      Summer School
      Dates:
      For how long:
      Evaluation from private entity
      Dates:
      For how long:
      Other Early intervention program
      Dates:
      For how long:
      Drop files here or
      Max. file size: 10 MB.

        There is HOPE.

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        4075 Old Western Row Rd, Mason, OH 45040

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        • What We Treat
        • Treatments
          • Adult Treatment
            • Outpatient Care
            • Acute Inpatient Care
            • Residential Treatment Programs
            • Adult Partial Hospitalization (PHP)
            • Eating Disorders Treatment
          • Child/Adolescent Treatment
            • Adolescent PHP
            • Acute Inpatient Care
            • Outpatient Care
          • Specialized Therapy Programs
            • Dialectical Behavioral Therapy (DBT)
            • Transcranial Magnetic Stimulation (TMS)
            • Electroconvulsive Therapy (ECT)
            • Assessment Programs
        • Patients & Family
          • Admissions
          • Patient Forms
          • Bill Pay
        • Refer a Patient
        • Why LCOH
          • Clinicians & Leadership
          • Careers
          • Affiliations & Accreditations
          • Stories of HOPE
        • Resources
          • Blog
          • News
          • Events
          • Library
        • I Want To
          • Sign into MyChart
          • Pay My Bill
          • Find a Clinician
          • Request Medical Records
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          • Give Feedback
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