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
ADULT 7 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?