Please fill out this form to the best of your knowledge. If some questions are not applicable to you or your child, write N/A. If you need more space or wish to make additional comments, please write on the back or attach a separate sheet.
Has your child had any of the following forms of psychological treatment? If so, how long did it last?
Number of the following the mother of the child has had (including the child being evaluated):
Formula Fed Nursed This is a fill in the How Long: field. Please add appropriate Any difficulties with feeding: fields and text.