(money management, benefits, living arrangements, clothing, personal care, child care, rent, other) Developmental History (Complete only for Children & Youth up to age 21 and everyone with ID/DD) During pregnancy, did mother use alcohol or other drugs? Yes No □ □ Describe any problems with the pregnancy or birth: Were developmental milestones met? Yes No (If no, explain) □ □ Was the first year of life difficult, easy, other? Yes No (If yes, explain) □ □ Describe any childhood accidents or injuries: School Functioning (Children & Youth up to age 21) Name of school: Does child/youth receive Special Education Services? Yes (If yes, complete release of information to obtain a copy of the current Individualized Education Plan (IEP)) □ No □ Additional Information (Children & Youth up to age 21) Comments on Educational Classification / Placement (please indicate if client is home schooled, in gifted program, etc.): Grades: Attendance: Previous Grade Retentions: Suspensions / Expulsions: Other Academic / School Concerns: Employment (adults only) (complete only if individual is not employed at the time of assessment) Barriers to Employment: Employment Related Needs: Previous Assessment History Have psychological, educational or functional assessments been completed in the last twelve months? Yes □ (If yes, complete release of information to obtain a copy of the applicable assessment.) If yes, indicate type of assessment__________________________________________________________________ No □ Current Legal Status Has the individual been involved with the legal system within the past twelve months? Yes No □ □ If yes, indicate type and number of arrest(s): Arrests: Yes No □ □ Number of arrests in the past 30 days: Pending Charges: Yes No If yes, indicate type and number of pending charges: □ □ Substance Use Related Issues: Is this person currently on parole and/or probation? Yes No □ □
(money management, benefits, living arrangements, clothing, personal care, child care, rent, other) Developmental History (Complete only for Children & Youth up to age 21 and everyone with ID/DD) During pregnancy, did mother use alcohol or other drugs? □ Yes □ No Describe any problems with the pregnancy or birth: Were developmental milestones met? □ Yes □ No (If no, explain) Was the first year of life difficult, easy, other? □ Yes (If yes, explain) □ No Describe any childhood accidents or injuries: School Functioning (Children & Youth up to age 21) Name of school: Does child/youth receive Special Education Services? □ Yes (If yes, complete release of information to obtain a copy of the current Individualized Education Plan (IEP)) □ No Additional Information (Children & Youth up to age 21) Comments on Educational Classification / Placement (please indicate if client is home schooled, in gifted program, etc.): Grades: Attendance: Previous Grade Retentions: Suspensions / Expulsions: Other Academic / School Concerns: Employment (adults only) (complete only if individual is not employed at the time of assessment) Barriers to Employment: Employment Related Needs: Previous Assessment History Have psychological, educational or functional assessments been completed in the last twelve months? □ Yes (If yes, complete release of information to obtain a copy of the applicable assessment.) If yes, indicate type of assessment__________________________________________________________________ □ No Current Legal Status Has the individual been involved with the legal system within the past twelve months? □ Yes □ No Arrests: □ Yes □ No If yes, indicate type and number of arrest(s): Number of arrests in the past 30 days: Pending Charges: □ Yes □ No If yes, indicate type and number of pending charges: Substance Use Related Issues: Is this person currently on parole and/or probation? □ Yes □ No
2015-Initial-Assessment-form-Revision-1.docx