Child History Questionnaire

Parent name*

Today’s Date*

Child’s name*

Child’s Age*

General Information

Child’s date of birth*

Child’s place of birth*

Siblings: No. & ages*

Describe relationship with siblings*

Describe child’s relationship with peers*

Describe how this child responds to discipline*

List child care givers who supervise child other than school or parent*

What concerns do you have regarding caregivers*

Describe any legal issues this child may have*

School Information

Name of School(s)*

Phone Number of School(s)*

Grade Child is in now*

Name(s) of Teacher(s)*

Is child in Regular Ed. or Special Ed.?*

Describe how this child functions in school*

What kinds of grades does this child get*

Describe any special educational needs*

If the child has been diagnosed with a specific disorder (e.g., SLD, EBD, EMH, DD, etc.) give name of professional who diagnosed (Dx) the disorder & date Dx made

What other information regarding your child’s school do you wish to share?

Health Issues of the Child

Child's physician*

Physician’s phone number*

Describe your child’s physical health*

Describe any medical problems during pregnancy with this child*

Describe any medical issues your child has now*

What medications is your child now taking?*

Describe any hospitalizations/surgeries for your child*

Describe any head injuries your child experienced*

Describe any special needs for your child*

Describe any emotional needs*

Describe any legal issues this child has*

Describe any alcohol or other substance abuse problems this child has*

Describe any behavior problems this child has*

Has the child been in counseling or psychotherapy?*

List the provider, dates of service, purpose of treatment and how long problem persisted*

What other information regarding your child’s health (physical or mental) do you wish to share?*

Developmental Milestones

When did the child:

first sleep through the night:*

crawl:*

speak their first words:*

achieve potty training:*

no longer require diapers:*

Describe any developmental delays*

Describe your child's strengths*

Parental Concerns

What concerns do you have about the other parent’s ability to meet this child’s needs?*

Describe anything about this child that we have not asked and you think is important for us to know*

What other information regarding your child that has not been asked that you wish to share?*

By signing below, I am attesting that the information I have given above is true and accurate, to the best of my ability.

Signature*

Reset

Date*

To be completed by each parent for each child

General Information

School Information

Health Issues of the Child

Developmental Milestones

Parental Concerns