Please fill out this form to the best of your knowledge. If some questions are not applicable to you, write N/A. If you need more space or wish to make additional comments, please write on the back or attach a separate sheet.
Have you had any of the following forms of psychological treatment? If so, how long did it last?
(Please circle: Birth, Adoptive, or Foster)
If applicable .
Number of the following your mother had?
Please check the following problems that may have occurred during labor:
Length of stay in hospital
Please list the approximate age at which you accomplished the following developmental milestones. If you feel the milestone is not appropriate yet for the age of your child, please write N/A. If unsure, please write DK
Major accidents or injuries:
Have any of your family members had the following problems/disorders? Please specify the family member’s relationship to you and whether the relationship is on the maternal (m) or paternal (p) side. Example: aunt (p) = aunt on the father’s side.
(Please attach a copy of the school evaluation if you have it)
Were you ever
Do you currently (within the past 6 months) display any of the following behaviors frequently?