Parent Questionnaire

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Parental Concerns
Please describe the major concerns you have in seeking help for your child. List your concerns in order of their importance to you.
1. (Most important)
2.
3.
4.
5.
Do the concerns you have for your child interfere with his/her daily routines at home/school? If yes, please explain.
Pregnancy History
If there was anything remarkable about the pregnancy or birth of your child, please describe.
Birth History
Was your child born:
Early term: Your baby is born between 37 weeks, 0 days and 38 weeks, 6 days.
Full term: Your baby is born between 39 weeks, 0 days and 40 weeks, 6 days.
Late term: Your baby is born between 41 weeks, 0 days and 41 weeks, 6 days.
Post-term: Your baby is born after 42 weeks, 0 days.
Was the child born by C-Section?
What was the reason for C-Section?
Child's Birth Weight
Child's Birth Length
Were there complications for the mother or baby at birth?
Please describe
If you child has had any other health problems not listed above, please describe them here.

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Development
Please share any information you’d like for us to know regarding your child’s developmental history.
(i.e. Did he/she meet developmental milestones on time?)
School History
Is your child currently enrolled in a school program?
Is your child currently enrolled in a school program?
Is your child attending school full-time or part-time?
School Name
School Address
School Phone
Grade (if applicable)
Teacher's Name
Has your child been evaluated by the school’s diagnostic team?
When was the evaluation completed?
Does the child currently have I.E.P. goals within the school district?
Please describe child's performance at school. What subjects does he/she do well in?
What subjects does he/she have difficulty with?
Are there behaviors in the classroom that have been of concern to his/her teacher?
Please describe
Are there any other family members (distant or close) with developmental or learning differences?
Please describe

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Social-Emotional Development
Does your child exhibit behaviors at home or school that concern you?
Please describe the behaviors that concern you and an example of a situation where this behavior has interfered.
What types of activities does your child typically choose to occupy his/her time?
Does your child have regular playmates or friends?
Describe any difficulties your child may have in social situations.
Describe your child’s strengths.
What frustrates your child?
What motivates your child?

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Insurance Information
Primary Insurance
Insurance Provider
Policy Name
Policy Number
Group Number
Referring Physician
Subscriber Name
Subscriber Date of Birth
Date Format: MM slash DD slash YYYY
Claims Address
Street Address Address Line 2 City State ZIP Code
Insurance Phone Number
Secondary Insurance
Insurance Provider
Policy Name
Policy Number
Group Number
Referring Physician
Subscriber Name
Subscriber Date of Birth
Date Format: MM slash DD slash YYYY
Subscriber/Servicemember Social Security Number (SSN)*
If Tricare insurance, list any prior civilian insurance and the policy number(s)
Claims Address
Street Address Address Line 2 City State ZIP Code
Insurance Phone Number

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About your child

Name	Relationship to Child

Doctor/Facility Name	Specialty