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Developmental History Form
Child Developmental History
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Indicates required field
1. Child's Name
2. Parent 1 Name, Age, and Occupation
3. Parent 2 Name, Age and Occupation
4. Was your child born at full term? If not how many weeks gestation. If born premature, what was the birth weight?
5. Were there any complications or significant stressors during the pregnancy and/or birth of your child?
6. Were there any problems with feeding your child?
7. Did your child have significant sleep difficulties as a baby? If so, did you try any particular method?
8. Were there any issues that affected your emotional attachment to your child? Eg. Postnatal depression/anxiety, significant absences, stressors.
9. Has your child suffered any significant illnesses, injuries or allergies? Eg. Brain injury, loss of consciousness, operations, hearing issues.
10. Has your child had any issues with hearing or vision? If yes, please detail issues and treatments.
11. Has your child ever experienced significant anxiety or low mood? Please describe.
12. Has your child experienced social difficulties? Eg. Making friends, keeping friends, bullying.
13. Does your child have difficulty keeping a bedtime routine, falling asleep, staying asleep or waking in the mornings, or with sleeping/getting to sleep on their own?
14. At what age did your child crawl? Walk?
15. At what age did your child say single words? Speak sentences?
16. Has your child had any difficulties with toileting, in the past or currently?
17. Has your child had any fine or gross motor difficulties? eg. Handwriting, using scissors, running, catching.
18. Has your child had any issues with concentration or attention? Can your child follow instructions?
19. Has your child required services from any of the following:
20. Please describe the reason and outcome of your child's involvement with the above services. Please upload copies of any reports or bring reports to the first session.
Max file size: 20MB
Max file size: 20MB
21. Please detail your child's history of/current attendance at child care arrangements.
22. Please describe any issues/difficulties at child care or kindergarten with settling, making friends, toileting, behaviours?
23. Please describe any issues/difficulties at school (if your child has or currently attends) in settling, friendships, getting along with others, academically, challenging behaviours, or repeating a grade?
24. Has your child experienced difficulty with:
25. Is there a family history of developmental difficulties, learning difficulties, mental health issues, or significant health problems? If yes, please describe:
26. How would you describe your parenting style? Do you follow a particular approach/philosophy?
27. Please note any other concerns you have for your child:
28. What are your child's strengths?
Thank you for taking the time to complete this information, it is very helpful for our assessment and will save time in the first sessions.
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