Parent Questionnaire

Date (YYYY-MM-DD)

Child’s Name

Parent’s Name

Occupation

Marital status:

Does your child have any siblings? How many? What ages?

What language is spoken in the home?

Please state 3 strengths your child has:

Please describe your child’s behavior concerns at home:

Please list your primary academic concerns:

Have there been any previous evaluations conducted in the past? If so, when and what were the results?

Does your child have a current diagnosis?(obligatorio)

Yes No

If yes, current diagnosis:

List 3 support systems your child has in their life right now:

What activities do you enjoy doing together as a family?

What activities does your child enjoy doing?

What makes your child angry?

What makes your child happy?

Does your child have age-appropriate and meaningful relationships with peers? (obligatorio)

Yes No

EDUCATIONAL HISTORY

Did your child attend preschool? Where? For how long? Any concerns during this time

What schools has your child attended for elementary and/or middle school? Please state the name of the school and what grade levels he attended there as well as any concerns during a specific time.

HEALTH & DEVELOPMENTAL HISTORY

Were there any complications/ stressors during pregnancy?

Were there any complications with labor/ delivery?

What was your child’s weight at the time of birth?

Did your child gain weight normally? (obligatorio)

Yes No

Were there any significant feeding problems or sleep problems during the first year of life?

To the best of your memory, at what age did your child do the following?

Crawl:

Walk:

First words: :

Toilet trained:

Describe any relevant details from the previews question, or write N/A if none:

Is your child taking any medications at the moment? (obligatorio)

Yes No

If yes, name of medications :

Thank you for your time in completing this valuable background information.

Thank you for your response. ✨