Child Developmental History
Clinician
*
Adrianne Smith
Allison Driscoll
Amy Burrell
Anthony Richardson
Ashley O’Connor
Berthania Boursiquot
Breanna Sansone
Carlie Dackson
Crystal Ramos
Daniel Resto
Danielle Casapulla
Danielle Triscari
Dori Reix
Elizabeth Gardner
Emily Nicefaro
George Ramirez
Gina Rodican
Hannah Geisler
Jessica DaRin
Jessica Ristorucci
Kaye Henry
Keegan Riccio
Kym McKoy
Melissa Lester
Meredith Lall
Michelle Sabatino
Pam Feroleto
Rebecca Halbert
Rebecca Kazlauskas
Sarah Miley
Sarah Yagovane
Shannon Pritchard
Starr Radin
Stephanie Swantek
Victoria Simeone
Program Admin
Please Select the Clinician instructed by the Intake Department \Staff member
Client Name
*
First Name
Last Name
Client ID #:
*
Adverse Prenatal/Perinatal Factors (family, health, exposures, other):
*
Characterization of Infant/Toddler:
*
Preschool Experiences (Daycare, Nursery School, Lessons):
*
Any problems with:
*
Early
Within Normal Limits
Late
Sitting
Walking
Language/Speaking
Hearing/Visual
Toilet Training
*
Yes
No
Unsure
Labor/Delivery
Eating
Sleeping
Behavior/Trantrums
Colicy
Activity Level
Separation
Enuresis/Encopreseis
Illness (i.e. Ear Infection)
Explanation:
Submit
Should be Empty: