Missing School Due Skipping Speech Problems to Illness Classes/School Poor School Work Learning Problems Additional Information: Developmental History Mother’s pregnancy was (circle Normal Complicated one): Please explain: Medication use during pregnancy? Please describe. Client’s condition at birth (circle Normal Abnormal one): Please explain: Birth Weight: As an infant, client was (check all that apply): Easy to Manage Irritable Demanding Alert/Responsive A Poor Eater A Poor Sleeper Additional Information: At what age did the client: Sit up unassisted Toilet trained Crawl Use words Walk without support Use sentences Toilet training was (circle Easy Difficult one): Notes: Significant Life Events Please indicate any important events in the client’s life (check all that apply): Change of Change of schools Marital conflict residence Change of custody Parents separated
Missing School Due to Illness Skipping Classes/School Learning Problems Speech Problems Poor School Work Additional Information: Developmental History Mother’s pregnancy was (circle one): Normal Complicated Please explain: Medication use during pregnancy? Please describe. Client’s condition at birth (circle one): Normal Abnormal Please explain: Birth Weight: As an infant, client was (check all that apply): Easy to Manage Alert/Responsive Irritable A Poor Eater Demanding A Poor Sleeper Additional Information: At what age did the client: Sit up unassisted Crawl Walk without support Toilet trained Use words Use sentences Toilet training was (circle one): Easy Difficult Notes: Significant Life Events Please indicate any important events in the client’s life (check all that apply): Change of residence Change of schools Change of custody Marital conflict Parents separated
Child-Intake-Form-for-web.docx