Parent Questionnaire

(Please complete the form to the best of your ability and return it prior to your evaluation appointment. The evaluating therapist will review this form and may probe for additional information during the evaluation. Please include copies of related evaluations/progress reports and/or current IEP’s).

Specialized Therapy Services
Child Name*
First Last
Date Of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
- Other
Ethnicity
Home Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Family Information and Background
Parent/Legal Guardian*
First Last
Occupation
Email
Enter Email Confirm Email
Cell Phone*
Parent/Legal Guardian (Additional)*
First Last
Occupation
Email
Enter Email Confirm Email
Cell Phone*
Current Marital Status
- Married
- Single
- Separated
- Divorced
How old was the child when the separation occurred?
How old was the child when the divorce occurred?
Child's Pediatrician | Hospital/Office/Location | Phone Number | Fax Number*
Other Members Of The Family: Relationship | Age | Speech/Hearing Problems*
Any siblings living outside the home?*
Please provide the siblings Name | Relationship | Age
Primary language spoken in the home:*
Other languages spoken by child or family. Is the child bilingual?
Please provide any background information that may be relevant to this assessment (family stressors, illnesses, changes in routine, recent losses, etc)*
Describe, in your own words, your child’s difficulties:*
Developmental Milestones
Please fill out, to the best of your knowledge, the month/year of age at which your child first accomplished the following:
Turned Over Stood (Alone)
Sat Alone 1st Word
Crawled Walked (Alone)
Babbled 2 Words Together
About how many words does your child say?
- 0-10
- 20-50
- 100-200
- 200+
My child uses the following to communicate (check all that apply)
- Words
- Gestures (reaching, pointing, etc.)
- Sign Language
- Device
- None
Has there been a regression of skills in the last 3 months?*
Please explain....
Does your child have a formal diagnosis?
How would you describe the status of your child's health?*
Has your child ever received therapy? Check all that apply:
- Speech
- OT
- PT
- Music Therapy
- ABA
Has your child had an official assessment?*
Where was the assessment made?
Attach FIles Here
Drop files here or

Max. file size: 50 MB.
Birth History
Mother age at the time of pregnancy: Length of labor:
Birth weight: Apgar score:
Multiple births yes/no Did the mother recieve prenatal care?
Please check mark all that occurred during the pregnancy:
- Difficulty with conception
- Convulsions
- Flu
- Frequent Use of Alcohol
- Use of non-prescription drugs
- X-Rays to abdomen
- Hypertension
- Accidents / Injury
- Frequent Hospitalizations
- Difficulty breathing
- Measles
- Toxemia
- Weight Loss
- Anesthesia
- RH Factor
- Emotional Problems
- Bleeding
- Nausea
Please check all that apply that occurred during/at birth:
- Unusual / Hard Labor
- Induced Labor
- Breech
- C-Section
- Instruments used
- Nuchal Cord (cord around neck)
Please describe any significant medical history ( I.e allergies, seizures, breathing difficulties, frequent colds, frequent ear infections, ear tubes, head injury, head injuries, vision/hearing problems, etc)
Please list any medications your child takes regularly/& why:
Please use the space below to elaborate/address concerns regarding the child’s behavior and development:
Current Speech - Language - Hearing
Has anyone else in the family ever had a speech / language / literacy / learning difficulty?
Has your child had a hearing test? If yes, when and results.....
Does your child.......(check any or all that apply)
- Repeat sounds, words or phrases over and over?
- Understand what you are saying?
- Retrieve/point to common objects upon request (ball, cup shoe)?
- Follow simple directions (Get your shoes)?
- Respond correctly to yes/no questions?
- Respond correctly to who/what/where/when/why questions?
- Does your child combine words (red ball, give me)?
- Does your child speak in sentences?
Please check all the behaviors that describe your child:
- Withdrawn
- Slow to learn
- Aggressive
- Shy
- Gives up easily
- Jealous
- Tires easily
- Talkative
- Clumsy
- Outgoing
- Follows rules
- Tantrums
- Leader
- Passive
Please check all the behaviors that describe your child:
- Stubborn
- Hyperactive
- Follower
- Difficulty making friends
- Generally happy
- Difficulty sharing
- cooperative
- Easily frustrated/impulsive
- Restless
- Poor Eye Contact
- Easily distracted/short attention
- Self-injurious behavior
- Self-stimulating behavior
- Willing to try new activities
Does your child’s play involve……
- Independent Play (parallel play, i.e., child plays alone near other children)
- Pretend Play (imaginative play, e.g., using a block as a pretend phone)
- Cooperative Play (games, shared play)
Feeding and Development
Did/does your child have any feeding problems (e.g., vomiting, reflux, difficulty with sucking/swallowing)  YES  NO Explain:
Did your baby transition easily to solid foods?  YES  NO Explain:
Does your child now tolerate a range of food types and textures?  YES  NO Explain:
Does your child frequently gag on solids?  YES  NO Explain:
Did your child use a dummy/pacifier?  YES  NO What age did your child cease (completely) using it? If your child is currently using a dummy, how often is it used?
Does your child have poor saliva control (e.g. drooling)  YES  NO
Do you have any concern for your child regarding the following?:
- Hand Dominance (e.g. swapping hands during tasks)
- Fine Motor Skills (using their hands and fingers e.g. holding a pencil, picking up small objects, etc.)
- Gross Motor Skills (big movements e.g. running, jumping, hopping, climbing, ball skills)
- Planning and organization (e.g. sequencing during daily activities)
- Sensory Issues (e.g. aversion or attraction to sound, touch, or specific items)
- Self-care (e.g. brushing teeth, dressing or toileting)
If any of the above were checkmarked, please explain here:
School Experiences
Is your child of shcool age?*
What school does your child attend and what grade?
What educational difficulties have you observed in your child?
Please list any outside interests or extracurricular activities that your child is involved in:
List your child's personal strengths:
Scheduling
Does your child take naps?*
What are his/her nap times?
Is your child potty trained?*
What is your preferred location for therapy services?*
What are your preferred times for therapy services?
Please list availability and any other appointments/commitments that we should know before scheduling?

*Please include dates/times
CAPTCHA

Turned Over	Stood (Alone)

Sat Alone	1st Word

Crawled	Walked (Alone)

Babbled	2 Words Together

Parent Questionnaire

Specialized Therapy Services

Family Information and Background

Developmental Milestones

Birth History

Current Speech - Language - Hearing

Feeding and Development

School Experiences

Scheduling