SECTION 1: BIO DATA
User Code (Sent To Your Email)
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Child’s Age
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Child’s Gender
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Child’s Date of Birth
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Phone Number
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Email
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Address
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Your Age
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Your Gender
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Date of Birth
Occupation
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Number of Hours Currently Working
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Not Working 0 – 15 hours a week 16 – 25 hours a week 26 – 40 hours a week 41 – 55 hours a week More than 55 hours a week
Relationship With Child
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How much time do you spend with the child per day (in hours)
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Phone Number of Child’s Physician
Address of Child’s Physician
Email of Child’s Physican
How long has your child been under this physician’s care? (in Years)
SECTION 2: WHY ARE YOU SEEKING HELP?
What are your concerns about your child? (Please provide a detailed explanation)
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What are the school’s primary concerns?
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Has your child been diagnosed as having any medical or educational condition?
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Option 1
If so, what?
Who made the diagnosis and when was it made?
Referred By (If not referred any anyone, write None)
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Relationship to child
SECTION 3: BEHAVIOUR
Behavioural Excesses: What does your child currently do too often, too much, or at the wrong times that gets him/her in trouble? Please list all the behaviours you can think of.
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Behavioural Deficits: What does your child fail to do as often as you would like, as much as you would like, or when you would like? Please list all the behaviours you can think of.
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Behavioural Assets: What does your child do that you like? What does he/she do that other people like?
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Assessment/Treatment Goals: From your preceding list of your child’s behaviour and your family concerns, what problem behaviours do you want to see change FIRST: and how much must they change for you to be satisfied?
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SECTION 4: MEDICAL HISTORY
Birth weight
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Apgars
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Pregnancy
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Full Term Pre Term
Did the child’s mother have any challenges during the pregnancy or at delivery? If so, please describe. if none, write none
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Please list any current medical or physical challenges. If none, write none
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General health at present
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Good Fair Poor
Please Describe
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How would you classify the child’s eating habit?
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Excellent Good Poor (too much) Poor (too little)
How would you classify the child’s sleeping habit
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Excellent Good Poor (too much) Poor (too little)
Names of child’s siblings: Age, Sex, Grade, School. If none, write none
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Relationship with siblings. If none, write none
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SECTION 5: OTHER HISTORY
Has your child ever experienced any type of abuse (physical, sexual, or verbal?)
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Yes No
If yes, please describe
Has your child ever made statements of wanting to hurt him/herself or seriously hurt someone else?
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Yes No
If yes, please describe
Has he/she ever purposely hurt himself or another
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Yes No
If yes, please decribe
Has your child ever experienced any serious emotional losses (such as a death of or physical separation from a parent or other caretaker)
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Yes No
If yes, please describe
What are some of the things that are currently stressful to your child and his/her family?
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So far, what solutions have been helpful?
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Where did you hear about us?
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Is there anything else that you would like us to know? (if none, write none)
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If you are human, leave this field blank.
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