Person providing information

Who does the child live with (tick all that apply)

Is your child

Describe the state of your child's current health.

Is your child currently taking medicine

Has your child ever been identified as having a speech, language or learning difficulty / disability?

Has your child received therapy services, other additional help, tutoring or counseling

Has your child had any of the following? Please check all that apply

My child sat up

My child crawled

My child walked alone

My child Spoke first words

My child Spoke short phrases

My child Spoke short sentences

My child was fully bladder trained

My child was fully bowel trained

My child stayed dry all night

Does your child have more difficulty than other children his/her age? Check all that apply

Does your child have difficulty getting ready for school or other activities?

Do you feel it is difficult for the child to keep track of things and stay organized?

Is your child doing any chores? (like tidying the room?)

Does your child need frequent reminder?

Does your child sleep well

How much of a struggle is homework?

Does your child receive any special school services/support? (IEP, 504 plan, Gifted/Talented, special ed)