the asc is a multi-departmental, collaborative center

Welcome to the Autism Spectrum Center (ASC) at Boston Children’s Hospital.

The ASC is a multi-departmental, collaborative center providing diagnosis, treatment, continuity of care and support services.

Date: _______________

Dear Parent/Guardian,

Thank you for your interest in the Autism Spectrum Center. The below steps will need to be completed before scheduling an appointment.

1. Complete and return all attached forms to our office by mail, email or fax. Please

note that the more information you can provide us before to your appointment, the more

productive the visit will be. You are also encouraged to make copies of forms for your

own records.

Mail to: Boston Children’s Hospital

Autism Spectrum Center

300 Longwood Avenue, Fegan 11

Boston, MA 02115

Email: [email protected]

Fax: 617-730-4823

2. Please include any relevant early intervention/school testing such as the most recent

copies of:

o IFSP (Individualized Family Service Plan-report from early intervention services)

o IEP (Individualized Education Program)/504 Accommodation Plan

o School district based CORE/TEAM evaluations (could include educational

testing, psychological testing, OT, PT, and/or speech and language evaluations).

o Any private or clinic-based testing (could include psychological testing,

neuropsychological evaluation, past medical diagnostic assessments, OT, PT

and/or speech and language evaluations).

3. Once we receive and review the information, the ASC intake team will contact you to

schedule an appointment.

We know this process can be complex and confusing. Please feel free to contact the Autism Spectrum Center if you have any questions by phone at 617-355-7493 or by email at [email protected]. You can also visit our website for information about our center: http://www.bostonchildrens.org/autismspectrumcenter

mailto:[email protected]

mailto:[email protected]

http://www.bostonchildrens.org/autismspectrumcenter

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SERVICES INCLUDE• A single point of access and a streamlined appointment

process for children with ASD and their families

• Multidisciplinary staff from Neurology, DevelopmentalMedicine, Psychiatry, Psychology, Genetics, Speechand Language, Gastroenterology, Occupational Therapy

• Diagnostic evaluation and follow-up care

• Resource Specialist, Social Work and Child Life Specialiststo better serve our patients

• Educational e-newsletter

• Autism friendly hospital initiative for optimizedpatient experience

• Parent Lecture Series presented by our faculty and guests

LOCATIONSBoston • Lexington • Peabody • Waltham • Weymouth

AUTISM SPECTRUM CENTERBOSTON CHILDREN'S HOSPITAL

A multi-departmental collaborative center providing diagnosis, treatment,

continuity of care, and support services for children with

Autism Spectrum Disorder (ASD) and their families.

617-355-7493

bostonchildrens.org/autismspectrumcenter

[email protected]

FOR MORE INFO

http://www.childrenshospital.org/autismspectrumcenter

mailto:autismcenter%40childrens.harvard.edu?subject=Autism%20Spectrum%20Center%20%28inquiry%20from%20flyer%29

INSURANCE INFORMATION

Your signature below indicates that you have been advised that you may be responsible for paying all charges associated with the visit.

I acknowledge that if any of the above referenced items or services are not considered medically necessary by my insurance company or are non-covered services, I am financially responsible for the full amount should the claim be denied. If I am denied insurance coverage for any service, discounts may be available.

Guarantor Name:

Parent/Guarantor Signature: Date:

1

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ASC INTAKE QUESTIONNAIRE

Use Plate, Label, or Print:

Name:

CH MRN#:

DOB: Gender: M F

© Boston Children’s Hospital, 2014 All rights reserved 1

Child’s Name: Last First

Date of Birth: __________________________________ Gender (circle): M F

The Autism Spectrum Center does not provide evaluations for child abuse and neglect, custody determination, immediate suicidality, IQ testing for gifted placement or assessment for acute psychiatric conditions. If you need any of the above services, please let us know and we can direct you to an appropriate provider.

Because the Autism Spectrum Center has a waiting list, some problems need more urgent attention. If your child has any of the following problems, please also contact your pediatrician. Please indicate if you have any urgent medical concerns including any of the following:

Y N Seizures Y N Loss of skills, developmental regression Y N Loss of hearing Y N Loss of vision Y N Difficulty swallowing, choking Y N Severe weakness or lack of coordination Y N Inability to tolerate exercise Y N Severe headache Y N Safety of any family members, including this child Y N Suicidal thinking or attempt of child or family members Y N Other (please describe):

___________________________________________________________________________________________

Do any of the following apply to this child: Y N DCF (formerly DSS) involvement Y N DDS (formerly DMR) involvement Y N Lives in residential facility

Please list the question(s) you would like answered by this evaluation (at least one REQUIRED):

1. _____________________________________________________________________________________

2. _____________________________________________________________________________________

3. _____________________________________________________________________________________

Who referred your child to the Autism Spectrum Center? (If a provider, please list name and specialty)

___________________________________________________________________________________________

Child’s Primary Care Provider (e.g. pediatrician, nurse practitioner)

___________________________________________________________________________________________

Date of last physical exam: _____________________________________________________________________

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ASC INTAKE QUESTIONNAIRE Name:

CH MRN#:


Parent/Caregiver 1 contact information

Full name: First _______________________________________ last ______________________________________

Relationship to child ___________________________________________________________________________

Home address Street___________________________________________________________________________

City/town_________________________________________________________________________

State_____________________________Zip_______________

Telephone (please check preferred number): home_____________ work____________ mobile____________

Email address _______________________________________________________________________________

Parent/Caregiver 2 contact information




City/town_________________________________________________________________________

State_____________________________Zip_______________


Email address _______________________________________________________________________________

Legal guardian (if different from above)




City/town_________________________________________________________________________

State_____________________________Zip_______________


Email address _______________________________________________________________________________

Child’s Living/Custody arrangement: please check if applicable, and complete table on next page

Child in guardianship Child in foster care Child in adoptive family Other (please describe): _____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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CH MRN#:


Language(s) spoken in the home:_________________________________________________________________

Y N Do you or your child require an interpreter for this evaluation?

Family religion _______________________________________________________________________________ How would you describe the child’s race or ethnicity? Please check all that apply:

American Indian/Alaska Native Asian Black/African American Native Hawaiian or other Pacific Islander White Latino/Hispanic Other race (please describe): _____________________________________________________________

Y N Has your child had a school (CORE, TEAM) evaluation? If yes, when? __________________________ Y N Does your child have an Individualized Education Plan (IEP)? If yes, date of IEP? _________________ Y N Has your child had any previous psychological testing? If yes, when? ___________________________

Please submit copies of the most recent Individualized Education Plan (IEP), and results of any previous academic, psychological, or school testing from the past 3 years. This information may be necessary for insurance referrals. Please indicate the documents that will be sent in:

Documents to be sent in Who will send these in: IEP, IFSP, IIIP Parent School Other: Academic, psychological, and/or school testing results Parent School Other: Other documents (describe):

Parent School Other:

Name of parent/caregiver or other person with guardianship or medical decision-making authority for the child

Is this person the child’s legal guardian?

Does this person have physical custody (child lives with this person)?

If yes, at what age did child come into home?

Caregiver 1 above Y N Y N

Caregiver 2 above Y N Y N

Other Y N Y N

Other Y N Y N

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Please check off any that apply to this child:

I have concerns about

Child has been diagnosed with

Medical, developmental, or psychological problem

Autism spectrum disorder, Asperger’s, Pervasive developmental disorder (PDD) ADHD, ADD Behavior Problems Developmental delay Emotional or psychiatric problem Learning problem Intellectual disability (formerly mental retardation) Speech/language delay, communication problems Fine motor problem Gross motor problem Epilepsy, seizures Problems with coordination, ataxia Severe weakness or inability to tolerate exercise Tics/Tourette’s Toileting problem (problems toilet training, bedwetting, soiling) Genetic or chromosomal condition Anxiety, Obsessive-Compulsive Disorder (OCD) Bipolar disorder or mood swings Depression

Please list any other current medical disorders (e.g. cerebral palsy, Down syndrome, sickle cell, asthma):

Y N Has your child ever been prescribed medication(s) for the concerns or diagnoses checked off above?

If yes, please list medication(s) and dose(s) if possible

Approximate dates of use

Did this medication effectively treat your child’s problem(s)?

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

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CH MRN#:


Y N Has your child ever received any mental health/counseling services?

If yes, please list type of service, provider’s name, and location/clinic

Approximate dates of service

Did this service effectively treat your child’s problem(s)?

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

Y N Not sure

Y N Is there anything else we should know about your child or your family?

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Parent/Guardian Sign Print Date Completed

Relationship to Patient

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CHILD AND FAMILY HISTORY QUESTIONNAIRE


Name:

CH MRN#:

DOB: Gender: M F




CHILD’S LIVING SITUATION Please list all those living in the child’s home: Name Relationship to

child Birthdate Highest grade or

degree completed Occupation (if applicable)

Are there any siblings not listed above? Y N If yes, please list names, ages, and where they live:

If one or both biological parents are not living in the home, how often does the child see the parent(s) not in the

home?

___________________________________________________________________________________________

Is there anything you would like us to know about the religious, spiritual, cultural beliefs, traditions, or practices of

your family or extended family?

___________________________________________________________________________________________

___________________________________________________________________________________________

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CHILD AND FAMILY HISTORY QUESTIONNAIRE Name:

CH MRN#:


CHILD’S BIRTH HISTORY Check if birth history is unknown

Age of mother at delivery: ______

Number of previous pregnancies (including miscarriages or terminations): _________

During pregnancy, did the mother: Y N Take prenatal vitamins

Y N Use tobacco If yes: how much?

Y N Drink alcohol If yes: how much?

Y N Take drugs or medications

If yes: what drug(s) or medication(s), and during which trimester(s):

Birth weight____________ Birth length ____________ Head circumference_________

Apgar score (if known): 1 minute ___ 5 minute ____

Was the baby born at term? Y N OR _____ number of weeks

Was the delivery vaginal cesarean (C-section)?

If cesarean, please describe why:

Were there any prenatal or neonatal complications? Y N

If yes, please describe:

Was a NICU or extended hospital stay required? Y N

If yes, please describe:

Was initial feeding formula breast milk

If breastfed, for how long? _______________

CHILD’S MEDICAL HISTORY

Check if child’s entire medical history is unknown Does the child have, or has the child ever had, any of the following DEVELOPMENTAL OR LEARNING PROBLEMS? Please describe or explain

Developmental delay or intellectual disability Y N Don’t know

Behavior problems Y N Don’t know

Attention or hyperactivity problems, ADHD, ADD Y N Don’t know

Autism spectrum disorder, Asperger’s, Pervasive Developmental Disorder (PDD)

Y N Don’t know

Learning problems, dyslexia Y N Don’t know

Speech or language delays Y N Don’t know

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CH MRN#:


Does the child have, or has the child ever had, any of the following MENTAL HEALTH PROBLEMS? Please describe or explain

Anxiety, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder Y N Don’t know

Attachment disorder Y N Don’t know

Depression Y N Don’t know

Suicidal thoughts or attempts Y N Don’t know

Bipolar disorder Y N Don’t know

Schizophrenia or psychosis Y N Don’t know

Does the child have, or has the child ever had any of the following CONGENITAL, METABOLIC, OR SENSORY PROBLEMS?

Please describe or explain

Down syndrome/Trisomy 21 Y N Don’t know

Other genetic or chromosomal disorder Y N Don’t know

Metabolic disorder Y N Don’t know

Frequent ear infections Y N Don’t know

Problems with ears or hearing Y N Don’t know

Problems with eyes or vision Y N Don’t know

Does the child have, or has the child ever had, any of the following NEUROLOGIC PROBLEMS? Please describe or explain

Frequent headaches, migraines Y N Don’t know

Head injury, concussion, loss of consciousness Y N Don’t know

Epilepsy, convulsions, or seizures Y N Don’t know

Tics or Tourette’s Y N Don’t know

Meningitis Y N Don’t know

Cerebral Palsy Y N Don’t know

Fine or gross motor delays Y N Don’t know

Does the child have, or has the child ever had, any of the following HEART (CARDIAC) PROBLEMS? Please describe or explain

Heart murmur Y N Don’t know

Heart rhythm problem, irregular heart rate, long QT syndrome, Wolff-Parkinson-White

Y N Don’t know

Congenital heart problem Y N Don’t know

Cardiomyopathy Y N Don’t know

Other (specify): Y N Don’t know

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CH MRN#:


Does the child have, or has the child ever had, any of the following OTHER HEALTH PROBLEMS? Please describe or explain

Dental decay Y N Don’t know

Sleep problems, snoring, restless sleep, apnea Y N Don’t know

Allergies Y N Don’t know

Chronic or recurrent skins problems (e.g. eczema, acne) Y N Don’t know

Asthma, bronchitis, bronchiolitis, pneumonia Y N Don’t know

Overweight, obesity Y N Don’t know

Diabetes Y N Don’t know

Thyroid or other endocrine problems Y N Don’t know

Growth problems Y N Don’t know

Feeding problems Y N Don’t know

For

girls:

Age of first period (menses) Not applicable Age:

Problems with periods (menses) Not applicable Y N

Pregnancy Not applicable Y N

Daytime bowel or urine accidents (over age 5) Y N Don’t know

Nighttime bedwetting (over age 5) Y N Don’t know

Frequent abdominal pain Y N Don’t know

Constipation requiring doctor visits Y N Don’t know

Celiac disease Y N Don’t know

Kidney disease or urologic problem Y N Don’t know

Anemia or bleeding problem Y N Don’t know

Immune deficiency or HIV Y N Don’t know

Cancer Y N Don’t know

Joint disease, arthritis, rheumatologic

problem Y N Don’t know

Alcohol or drug use Y N Don’t know

Tobacco use Y N Don’t know

Other health problems (please specify):

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CH MRN#:


Has the child ever experienced any of the following? If yes, when and where? Hospitalized overnight Y N Don’t know

Surgery Y N Don’t know

Injuries, fractures, ingestions Y N Don’t know

Elevated lead level Y N Don’t know

Family violence Y N Don’t know

Has the child ever had any of the following screening/diagnostic tests or procedures?

If yes, when, where, and results? (Please send in copies of results if available)

Genetic testing Y N Don’t know

EEG Y N Don’t know

CT scan or MRI of the head Y N Don’t know

Sleep study Y N Don’t know

Hearing test Y N Don’t know

Vision test Y N Don’t know

BIRTH (BIOLOGICAL) FAMILY MEDICAL HISTORY

Check if the entire birth family history is unknown

Are there any birth family members who have had any the following DEVELOPMENTAL OR LEARNING PROBLEMS?

If yes: please indicate who and whether on mother’s or father’s side of the family

Developmental disability or intellectual disability Y N Don’t know

Attention or hyperactivity problems, ADHD, ADD Y N Don’t know

Autism spectrum disorder, Asperger’s, Pervasive Developmental Disorder (PDD)

Y N Don’t know

Learning problems, dyslexia Y N Don’t know

Speech or language problems Y N Don’t know

Are there any birth family members who have had any the following MENTAL HEALTH PROBLEMS?


Anxiety, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder Y N Don’t know

Depression Y N Don’t know

Suicide or attempted suicide Y N Don’t know

Bipolar disorder Y N Don’t know

Schizophrenia or psychosis Y N Don’t know

Other (please specify): Y N Don’t know

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CH MRN#:


Are there any birth family members who have had any of the following CONGENITAL, METABOLIC, OR SENSORY PROBLEMS?


Down syndrome/Trisomy 21 Y N Don’t know

Other genetic or chromosomal disorder Y N Don’t know

Metabolic disorder Y N Don’t know

Childhood hearing loss Y N Don’t know

Visual impairment Y N Don’t know

Other (please specify):

Are there any birth family members who have had any of the following NEUROLOGIC PROBLEMS?


Frequent headaches, migraines Y N Don’t know

Epilepsy, convulsions, or seizures Y N Don’t know

Tics or Tourette’s Y N Don’t know

Dementia or Alzheimer’s Y N Don’t know


Are there any birth family members who had had any of the following HEART-RELATED (CARDIAC) PROBLEMS?


Heart disease (before 55 years old) Y N Don’t know

Heart rhythm problem, irregular heart beats, long QT syndrome, Wolff-Parkinson-White

Y N Don’t know

Hypertrophic cardiomyopathy Y N Don’t know

High cholesterol or takes cholesterol medication

Y N Don’t know

High blood pressure Y N Don’t know

Sudden unexplained death Y N Don’t know

Marfan syndrome Y N Don’t know


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Are there any birth family members who have had any of the following OTHER HEALTH PROBLEMS?


Allergies Y N Don’t know

Immune problems, HIV, or AIDS Y N Don’t know

Asthma Y N Don’t know

Obstructive sleep apnea Y N Don’t know

Cancer (before 55 years old) Y N Don’t know

Overweight, obesity Y N Don’t know

Diabetes Y N Don’t know

Thyroid or other endocrine problems Y N Don’t know

Growth problems Y N Don’t know

Liver disease Y N Don’t know

Kidney or bladder disease Y N Don’t know

Bedwetting (after 5 years old) Y N Don’t know

Muscle disease (e.g. Duchenne) Y N Don’t know

Alcohol or drug use Y N Don’t know

Tobacco use Y N Don’t know

Other health problem (please specify):

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CH MRN#:


CHILD’S DEVELOPMENTAL HISTORY As best as you can remember, list the age or check off the approximate time at which your child reached the following developmental milestones.

Developmental Skill Age (if known) Not yet Only if exact age cannot be recalled

Early At Normal Time Late

Sat without support

Crawled

Stood without support

Walked without assistance

Spoke first words

Said phrases

Said sentences

Bowel trained

Bladder trained, day

Bladder trained, night

CHILD’S CHILD CARE/SCHOOL HISTORY

Check here if your child is not yet in child care or school, and skip this page Has the child ever experienced or received any of the following school interventions?

If yes, please describe, and specify what grade(s) and/or subject(s), if applicable

Early Intervention Program or special needs daycare/preschool

Y, in the past Y, current N Don’t know

Speech, occupational, or physical therapy


Summer school Y, in the past Y, current N Don’t know

Repeated a grade Y, in the past Y, current N Don’t know

Special education services (e.g. 504 plan, IEP)


Disciplinary actions (detention, suspension, expulsion)


Special medical assistance at school


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HISTORY OF SCHOOL PROBLEMS: Please describe any problems that occurred during each of the following grades

Academics Behavior

Preschool

Kindergarten, first grade

Second and third grades

Fourth and fifth grades

Sixth through eighth grade

High School

Parent/Guardian Sign Print Date Completed


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CURRENT FUNCTIONING UNDER 5


Name:

CH MRN#:

DOB: Gender: M F



Date of Birth: __________________________________ Gender (circle): M F CHILD’S GENERAL HEALTH When was the child’s last visit with his or her primary care provider? ______________________

Y N Has the child seen a dentist in the last year? Y N Are the child’s immunizations up to date?

CHILD’S MEDICATIONS

Child does not take any medications Name of medication Strength Dose Frequency, when

given Comments

Example: Concerta 36 mg 1 tablet Once each morning

Only on school days

Does the child currently take or use any of the following:

Vitamins (list):

Herbal preparations (list):

Dietary supplements (e.g. melatonin, omega 3) (list):

Special diets (describe):

CHILD’S ALLERGIES Please list any FOODS or MEDICATIONS to which the child has an allergy:

Child does not have any known allergies to foods or medications

Food or medication Describe reaction Example: amoxicillin Rash

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CURRENT FUNCTIONING UNDER 5 Name:

CH MRN#:


CHILD’S CURRENT OR RECENT (WITHIN 6 MONTHs) PHYSICAL SYMPTOMS Please check off any of the following symptoms experienced by the child currently or within the past 6 months. General/constitutional:

Significant behavioral changes Significant weight loss or gain Weakness or fatigue Fever or chills Sleep problem (difficulty getting to sleep or

staying asleep) Allergy:

Itchy or watery eyes Itchy or runny nose, sneezing Hives Needed to use Epi-Pen

Eyes, Ears, Nose, Throat:

Sore throats Ear infections Sinus infections Loud snoring, irregular breathing during sleep Problems with eyes/vision Problems with ears/hearing

Heart:

Chest pain or pressure Heart racing, skipped beats Ankle swelling, cold/blue hands, feet Fainting, fatigue with exercise

Lungs:

Cough Shortness of breath, wheezing Recent chest X-ray

Gastrointestinal:

Changes in appetite Abdominal pain or discomfort Constipation Diarrhea Bloating, indigestion Nausea, vomiting Change in bowel habits (number or

consistency) Blood in stool Jaundice (yellow skin or eyes), itching

Skin:

Rashes Changes in mole or spot Needed stitches

Genitourinary:

Nighttime bedwetting Daytime urine accidents Pain with urination Frequent urination Blood in urine Genital rashes or lumps Heavy or painful menses (periods)

Neurological:

Headaches Dizziness, vertigo Fainting, blackouts Weakness Numbness, tingling Seizures, convulsions Head injuries, concussions Limp Tremor, unusual motor movement (tics) Problems with coordination Problems with concentration, memory

Endocrine:

Sweating Fatigue Hand trembling Neck swelling Skin, hair, voice changes Thirst Growth difficulties

Bones, joints, and muscles (Rheumatologic/Musculoskeletal):

Joint pain, stiffness, swelling Fingers painful/blue in cold Dry mouth, red eyes Back, neck pain Muscle problems Fractures, broken bones Sprains

Hematologic:

Bruise easily, difficulty stopping bleeding Lumps under arms or on neck

Y N Are there any other symptoms not listed

above that you are concerned about? If yes, please

describe:

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CH MRN#:


EARLY CHILDHOOD SCREENING ASSESSMENT Circle the number that best describes this child compared to other children the same age. For each item, please circle the + if you are concerned and would like help with the item.

Rarely/ Not True

Sometimes/ Sort of

Almost always/ Very

true

Concerned?

1. Seems sad, cries a lot 0 1 2 + 2. Is difficult to comfort when hurt or distressed 0 1 2 + 3. Loses temper too much 0 1 2 + 4. Avoids situations that remind of scary events 0 1 2 + 5. Is easily distracted 0 1 2 + 6. Hurts others on purpose (biting, hitting, kicking) 0 1 2 + 7. Doesn’t seem to listen to adults talking to him/her 0 1 2 + 8. Battles over food and eating 0 1 2 + 9. Is irritable, easily annoyed 0 1 2 + 10. Argues with adults 0 1 2 + 11. Breaks things during tantrums 0 1 2 + 12. Is easily startled or scared 0 1 2 + 13. Tries to annoy people 0 1 2 + 14. Has trouble interacting with other children 0 1 2 + 15. Fidgets, can’t sit quietly 0 1 2 + 16. Is clingy, doesn’t want to separate from parent 0 1 2 + 17. Is very scared of certain things (needles, insects) 0 1 2 + 18. Seems nervous or worries a lot 0 1 2 + 19. Blames other people for mistakes 0 1 2 + 20. Sometimes freezes or looks very still when scared 0 1 2 + 21. Avoids foods that have specific feelings or tastes 0 1 2 + 22. Is too interested in sexual play or body parts 0 1 2 + 23. Runs around in settings when should sit still (school, worship) 0 1 2 + 24. Has a hard time paying attention to tasks or activities 0 1 2 + 25. Interrupts frequently 0 1 2 + 26. Is always “on the go” 0 1 2 + 27. Reacts too emotionally to small things 0 1 2 + 28. Is very disobedient 0 1 2 + 29. Has more picky eating than usual 0 1 2 + 30. Has unusual repetitive behaviors (rocking, flapping) 0 1 2 + 31. Might wander off if not supervised 0 1 2 +

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Circle the number that best describes this child compared to other children the same age. For each item, please circle the + if you are concerned and would like help with the item. 32. Has a hard time falling asleep or staying asleep 0 1 2 + 33. Doesn’t seem to have much fun 0 1 2 + 34. Is too friendly with strangers 0 1 2 + 35. Has more trouble talking or learning to talk than others 0 1 2 + 36. Is learning or developing more slowly than other children 0 1 2 + 37. I feel too stressed to enjoy my child 0 1 2 + 38. I get more frustrated than I want to with my child’s behavior 0 1 2 + 39. I feel down, depressed, or hopeless 0 1 2 + 40. I feel little interest or pleasure in doing things 0 1 2 + Are you concerned about this child’s emotional or behavioral development (please circle only one)?

Yes Somewhat No

CHILD’S OVERALL FUNCTIONING Please summarize your child’s OVERALL FUNCTIONING (i.e., emotionally, behaviorally, socially, academically, etc.) by choosing ONE number below. Compare your child’s functioning in 3 settings—home, school, and with peers—to “average children” his/her age that you are familiar with from your experience. Please circle only one number.

1 Excellent functioning/No impairment in settings

2 Good functioning/Rarely shows impairment in settings

3 Mild difficulty in functioning/Sometimes shows impairment in settings

4 Moderate difficulty in functioning/Usually shows impairment in settings

5 Severe difficulties in functioning/Most of the time shows impairment in settings

6 Needs considerable supervision in all settings to prevent from hurting self or others

7 Needs 24-hour professional care and supervision due to severe behavior or gross impairment(s)

Have there been any other recent changes in your child’s physical, emotional, psychological, or behavioral health that you are concerned about? Please describe:

Parent/Guardian Sign Print Date Relationship to Patient

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EARLY CHILDHOOD EDUCATIONAL QUESTIONNAIRE


Name:

CH MRN#:

DOB: Gender: M F




Child’s classroom/age level

Please have early intervention, child care and/or school personnel fill out and return

Parent’s name first last

Child care/School

Child care/School address

Form completed by Position

With help from

Contact Person

Phone number and best time to call

Email address

List up to 3 specific questions you would like answered as a result of this evaluation that would help you better meet this child’s developmental and educational needs

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

In your opinion, what areas of this child’s functioning need the most improvement?

Please describe the child’s strengths.

Please describe any other concerns you have about this child.

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PRE K SCHOOL QUESTIONNAIRE Name:

CH MRN#:


Besides English, are there any additional languages used for the child’s instruction? If yes, what language? ____________________________________________________

ACADEMIC READINESS: Please check the appropriate column

Not Yet Progressing Proficient A. Basic Concepts

1. Knows colors 2. Knows letters of alphabet 3. Knows numbers and counts past 10 4. Adds and subtracts things 5. Size concepts 6. Location concepts

B. Language and Communication 1. Uses speech to communicate 2. Explains and describes things 3. Rhymes words and remembers poems/songs 4. Uses uncommon words 5. Uses long sentences 6. Tells or retells stories or events 7. Speaks understandably 8. Follows oral instructions on level with peers 9. Uses correct grammar (e.g. verb tense) 10. Uses sign language or other communication

system

11. Follows classroom routine C. Emergent Literacy

Listens to stories in books 1. Asks questions about words 2. Reads words on signs and labels 3. Reads words in books 4. Recites books from memory 5. Reads “easy” books 6. Writes or copies words 7. Dictates stories 8. Writes “little” stories 9. Answers questions about orally read story

D. Motor Skills 1. Constructs puzzles or builds things 2. Uses pencils and pens correctly 3. Uses scissors well 4. Copies and traces shapes 5. Draws recognizable objects 6. Is coordinated on outdoor recess activities 7. Ties shoe laces

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EARLY CHILDHOOD SCREENING ASSESSMENT

Circle the number that best describes this child compared to other children the same age. For each item, please circle the + if you are concerned.

Rarely/ Not True

Sometimes/ Sort of

Almost always/ Very

true

Concerned?

1. Seems sad, cries a lot 0 1 2 + 2. Is difficult to comfort when hurt or distressed 0 1 2 + 3. Loses temper too much 0 1 2 + 4. Avoids situations that remind of scary events 0 1 2 + 5. Is easily distracted 0 1 2 + 6. Hurts others on purpose (biting, hitting, kicking) 0 1 2 + 7. Doesn’t seem to listen to adults talking to him/her 0 1 2 + 8. Battles over food and eating 0 1 2 + 9. Is irritable, easily annoyed 0 1 2 + 10. Argues with adults 0 1 2 + 11. Breaks things during tantrums 0 1 2 + 12. Is easily startled or scared 0 1 2 + 13. Tries to annoy people 0 1 2 + 14. Has trouble interacting with other children 0 1 2 + 15. Fidgets, can’t sit quietly 0 1 2 + 16. Is clingy, doesn’t want to separate from parent 0 1 2 + 17. Is very scared of certain things (needles, insects) 0 1 2 + 18. Seems nervous or worries a lot 0 1 2 + 19. Blames other people for mistakes 0 1 2 + 20. Sometimes freezes or looks very still when scared 0 1 2 + 21. Avoids foods that have specific feelings or tastes 0 1 2 + 22. Is too interested in sexual play or body parts 0 1 2 + 23. Runs around in settings when should sit still (school, worship) 0 1 2 + 24. Has a hard time paying attention to tasks or activities 0 1 2 + 25. Interrupts frequently 0 1 2 + 26. Is always “on the go” 0 1 2 + 27. Reacts too emotionally to small things 0 1 2 + 28. Is very disobedient 0 1 2 + 29. Has more picky eating than usual 0 1 2 + 30. Has unusual repetitive behaviors (rocking, flapping) 0 1 2 + 31. Might wander off if not supervised 0 1 2 + 32. Has a hard time falling asleep or staying asleep 0 1 2 +

Web Version


CH MRN#:


Circle the number that best describes this child compared to other children the same age. For each item, please circle the + if you are concerned. 33. Doesn’t seem to have much fun 0 1 2 + 34. Is too friendly with strangers 0 1 2 + 35. Has more trouble talking or learning to talk than others 0 1 2 + 36. Is learning or developing more slowly than other children 0 1 2 + Are you concerned about this child’s emotional or behavioral development (please circle only one)?

Yes Somewhat No

CHILD’S OVERALL FUNCTIONING Please summarize this child’s OVERALL FUNCTIONING (i.e., emotionally, behaviorally, socially, academically, etc.) by choosing ONE number below. Compare this child’s functioning in child care/school and with peers to “average children” his/her age that you are familiar with from your experience. Please circle only one number.

1 Excellent functioning/No impairment in settings

2 Good functioning/Rarely shows impairment in settings

3 Mild difficulty in functioning/Sometimes shows impairment in settings

4 Moderate difficulty in functioning/Usually shows impairment in settings

5 Severe difficulties in functioning/Most of the time shows impairment in settings

6 Needs considerable supervision in all settings to prevent from hurting self or others

7 Needs 24-hour professional care and supervision due to severe behavior or gross impairment(s)

Please describe this child’s social-emotional functioning, including moods and relationship with peers. Please describe this child’s behavior. Is there any other information you think would be helpful for evaluating this child?

Teacher Sign Print Date Completed


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