Referral for Multidisciplinary Team Evaluation (K-6)

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Referral for Multidisciplinary Team Evaluation (K-6)
Page 6 of 9
PARENT/GUARDIAN COMPLETES THIS SECTION
Student’s Name: ______________________________
School: ________________________________
II.
FAMILY-DEVELOPMENTAL-HEALTH-SCHOOL HISTORY
Name of person providing information ________________________________________________________
Relationship to student _____________________________________________________________________
A.
Family Information
Mother's name
Age
Education ______________
Employer
Phone: Home
Business _____________
Father's name
Age
Education _______________
Employer
Phone Home
Business ______________
Stepparent's name
Age
Education _______________
Employer
Phone Home
Business ___________
Marital status of parents _____________________________________________________________________
If parents are separated or divorced, how old was the child when the separation occurred? _________________
Does the child see the non-custodial parent? Yes _____ No ______If yes, how often?_____________________
Is child adopted? Yes___ No___ If yes, at what age? ______ Does child know of adoption? Yes____ No____
Has the child been in foster care? ____yes ____no If yes, when? __________ with whom?________________
__________________________________________________________________________________________
List all people living in household
Name
Relationship to Child
Age
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If any brothers or sisters are living outside the home, list their names and ages ___________________________
__________________________________________________________________________________________
Primary language spoken at home
Other languages spoken at home _______________
Is there a history of learning and/or behavioral problems in the family? Yes ______ No _______
If yes, list family member(s) and describe ____________________________________________
____________________________________________________________________________________
Describe your child’s typical routine in the morning prior to going to school (i.e. time awake? breakfast? any
difficulties getting ready for school/getting out the door? etc.) _______________________________________
__________________________________________________________________________________________
Referral for Multidisciplinary Team Evaluation (K-6)
Page 6 of 9
PARENT/GUARDIAN COMPLETES THIS SECTION
Student’s Name: ______________________________
School: ________________________________
II.
FAMILY-DEVELOPMENTAL-HEALTH-SCHOOL HISTORY
Name of person providing information ________________________________________________________
Relationship to student _____________________________________________________________________
A.
Family Information
Mother's name
Age
Education ______________
Employer
Phone: Home
Business _____________
Father's name
Age
Education _______________
Employer
Phone Home
Business ______________
Stepparent's name
Age
Education _______________
Employer
Phone Home
Business ___________
Marital status of parents _____________________________________________________________________
If parents are separated or divorced, how old was the child when the separation occurred? _________________
Does the child see the non-custodial parent? Yes _____ No ______If yes, how often?_____________________
Is child adopted? Yes___ No___ If yes, at what age? ______ Does child know of adoption? Yes____ No____
Has the child been in foster care? ____yes ____no If yes, when? __________ with whom?________________
__________________________________________________________________________________________
List all people living in household
Name
Relationship to Child
Age
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If any brothers or sisters are living outside the home, list their names and ages ___________________________
__________________________________________________________________________________________
Primary language spoken at home
Other languages spoken at home _______________
Is there a history of learning and/or behavioral problems in the family? Yes ______ No _______
If yes, list family member(s) and describe ____________________________________________
____________________________________________________________________________________
Describe your child’s typical routine in the morning prior to going to school (i.e. time awake? breakfast? any
difficulties getting ready for school/getting out the door? etc.) _______________________________________
__________________________________________________________________________________________
Referral for Multidisciplinary Team Evaluation (K-6)
Page 7 of 9
Describe your child’s typical routine after school: ____________________________________________
_____________________________________________________________________________________
Describe your child’s typical homework routine (i.e. when/where, how long, how much assistance is needed,
etc)________________________________________________________________________ ______________
__________________________________________________________________________________________
What conditions at home could be influencing your child's behavior and/or achievement in school (i.e., marital
problems, conflicts, illness of family members)?
__________________________________________________________________________________________
Has your child received professional counseling? Yes
No _____
If yes, date of initiation
until _____________________
Name of agency
Therapist
Reason and Outcome ____________________________________________________________
B.
Developmental/Medical History
Does the mother have a history of any medical problems, drug or alcohol abuse, etc? Yes ______ No _______
If yes, please describe ________________________________________________________________
Does the father have a history of any medical problems, drug or alcohol abuse, etc.?
Yes ______ No _______
If yes, please describe ________________________________________________________________
During the pregnancy, was mother on medication? Yes
No ______
If yes, what kind? ___________________________________________
During the pregnancy, did mother smoke? Yes
No ______
If yes, how many cigarettes each day? ____________________
During the pregnancy, did mother drink alcoholic beverages? Yes
No _______
If yes, what did she drink? _____________________________________________
Approximately how much alcohol was consumed each day? ___________________
During the pregnancy, did mother use drugs? Yes
No ______
If yes, what kind? ________________________
How frequently? ________________________
Was your child premature? Yes
No
If yes, by how many months?_____________________
Was a Cesarean section performed? Yes
No _____
If yes, for what reason? _______________________________________________________________
What was your child's birth weight? ___________________
Were there any birth defects or complications? Yes
No
If yes, please describe: ____________
__________________________________________________________________________________________
The following is a list of infant and preschool behaviors. Please indicate the age at which your child first
demonstrated each behavior. If you are not certain of the age but have some idea, write the age followed by a
question mark. If you don't remember the age at which the behavior occurred, please write a question mark.
Behavior
Age
Behavior
Age
Sat alone
Put several words together
______
Crawled
Became toilet trained
______
Walked alone
Stayed dry at night
______
Spoke first word
______
Describe your child’s early language development: _______________________________________________
_________________________________________________________________________________________
Does your child have any speech problems? Yes____ No____ If yes, describe___________________________
Did your child previously receive speech/language therapy? Yes ____ No ____
Referral for Multidisciplinary Team Evaluation (K-6)
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Were there any special problems in the growth/development of your child during the first few years?
Yes
No
If yes, describe ____________________________________________________
__________________________________________________________________________________________
Please list any serious illnesses, injuries, or surgeries your child has had. Also, note the approximate date (or
child's age at the time) ______________________________________________________________________
Has your child ever been hospitalized? Yes
No
If yes, length of stay: __________________
Reason: _____________________________
Has your child ever experienced seizures? Yes ______ No ____
If yes, describe______________________
__________________________________________________________________________________________
C.
Present Health
Child’s Physician _________________________________________________________________________
Does your child presently have any medical problems (illnesses, etc.)? Yes
No ____
If yes, describe _________________________________________________________________
____________________________________________________________________________________
Diagnosed when?_____________________________________________________________________
Does your child take any medication on a regular basis? Yes
No ______
If yes, Medication Name
Purpose
Dosage
Start Date
Side Effect
________________________
________________________
________________________
________________________
Place ** next to medications listed above which are taken at school.
Medications taken in the past, but not presently ___________________________________________________
__________________________________________________________________________________________
Has anyone suggested to you that your child may benefit from medication? Yes ___ No ___
If yes, describe _____________________________________________________________________
Does your child have any vision problems? Yes
No _____
Date of last exam
Physician ________________ Results ________________________
Does your child have any hearing problems? Yes
No _____
Date of last exam
Physician/audiologist ___________ Results ____________________
Has the child ever had tubes in his/her ears? Yes
No
If yes, when?_________________
Does your child have any difficulties with:
Large motor skills (i.e. walking, riding a bike, etc.)?
Yes ____ No ___ Describe: ____________
____________________________________________________________________________________
Small motor skills (i.e. using hands, drawing/cutting/writing, etc.)? Yes ____ No ___ Describe: ______
____________________________________________________________________________________
Does your child have difficulties with any of the following? If yes, describe on the lines below:
Grinds teeth
Yes ___ No ___
Mouths clothes/inedible objects
Yes ___ No ___
Avoids eye contact
Yes ___ No ___
Negative reaction to being touched Yes___ No ___
Negative reaction to sounds Yes ___ No ___
Unusual reaction to pain
Yes ___ No ___
Seeks or avoids odors
Yes ___ No ___
Extremely limited food preferences Yes ___ No ___
Describe any Yes answer above: _______________________________________________________________
Referral for Multidisciplinary Team Evaluation (K-6)
Page 9 of 9
D.
School History
Please list in order the previous schools the child has attended
SCHOOL
LOCATION
GRADES
DATES
______________
______________
______________
______________
Has your child been retained? Yes
No
If yes, what grade:
Why? ____________
Has your child ever received special tutoring or therapy in school? Yes
No _____
If yes, describe _________________________________________________________________
Has your child received tutoring out of school? Yes _____ No _____
If yes, describe _________________________________________________________________
Has your child ever been formally evaluated? Yes
No
If yes, when and by
whom?_____________
Results (please provide copy) ___________________________________________________________
Describe your child’s interests ________________________________________________________________
_________________________________________________________________________________________
What are the positive characteristics that describe your child socially/emotionally?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
From the parent/guardian perspective, describe your child's current difficulties (academic or behavioral)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
When were these difficulties first noticed? _________________________________________________
What seems to help? __________________________________________________________________
What seems to make them worse? ________________________________________________________
Does your child exhibit any unusual or atypical behaviors for his/her age? Yes _____ No ____ If yes, describe:
__________________________________________________________________________________________
Has your child been seen by the school social worker? If so, describe the reason _________________________
__________________________________________________________________________________________
Describe anything else that the assessment team should know about your child__________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are the best days/times for you to meet: Days: _________________ Times: ______________________
Phone #: ____________________________________________

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