85 Old Kings Highway North, Darien, CT 06820 Tel: 203-202-7654 | Fax: 203-202-7655 | www.southfieldcenter.com
The Southfield Center for Development ASSESSMENT AND DIAGNOSTIC SERVICES – CLINICAL INTAKE FORM Client Information
Date Completed by (Name) Relationship to Child
Childs Full Name Sex
Age Date of Birth Grade
School
Primary Language Language(s) spoken at Home
Home Address Home Phone
Parent Name Parent Name
Email Email
Cell Phone Cell Phone
Employer( Name and Address) Employer (Name and Address)
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How were you referred to The Southfield Center? Can we contact this reference? Yes No
Reference Contact Information:
Briefly describe the problem(s) /concern(s):
How long have the above problems existed?
Emergency Contact Information
Name Relationship
Address
Primary Phone Number Alternative Phone Number
Pediatrician
Address Phone Number
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Developmental History
Was your child adopted If Yes, where was your child born? How old was your child when placed in your care?
Yes No
Prenatal Development
Was this child conceived through In vitro Fertilization Did mother receive medicines to increase fertility?
Yes No Yes No
Number of ultrasounds during pregnancy Describe any abnormal findings:
Was the child a multiple birth? Was the child born first, second, etc.?
Yes No Yes No
Complications with Pregnancy
Please check any of the following complications experienced by the mother while pregnant with this child Anemia German Measles High Blood Pressure
RH Incompatibility
Toxemia Injury Bleeding Chronic Illness Surgery Threatened Miscarriage Other
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Please describe any complications endorsed above:
Please list and describe other complications/illnesses mother experienced during pregnancy: Please list any medications prescribed to mother during pregnancy:
Mother’s Health Habits While Pregnant
Did the mother smoke cigarettes while pregnant? If yes, how often?
Yes No
Did the mother drink alcohol while pregnant? If yes, how often?
Yes No
Did the mother use any drugs while pregnant? If yes, what type and how often?
Yes No
Birth History
How long was labor? (i.e. how many hours from first contractions to birth)
Was your baby born premature? If yes, how many days?
Yes No
After birth did your child stay in Well-Baby Nursery After birth did your child stay in Neonatal Intensive Care? Unit (NICU)?
Yes No Yes No
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Delivery/Post Delivery
Please check any of the following items that pertain to the delivery and post delivery of this child: Natural Childbirth Induced Breeched Cesarean Use of Anesthesia Use of Forceps Cord around neck Abnormal Color Baby did not cry right away Difficulty breathing Received Oxygen Received transfusion Received phototherapy Needed a respirator
Please describe any additional complications:
Please describe any medical problems your child had while in the nursery:
Did the mother and infant leave the hospital together? If not, please provide the reason:
Yes No
Early Infant Development
Please check any of the following items that describe the child in infancy: Poor Weight Gain Tremors Active Baby Convulsions Limp Difficulty sucking Stiff Difficulty chewing
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Was the baby colicky? If yes, how long?
Yes No
Was the baby breast fed? If yes, how long?
Yes No
Was the baby bottle fed? If yes, how long?
Yes No
Was/is your child on a special diet? If yes, please describe diet?
Yes No
Please describe any other feeding issues, sensitives, textures, reflux, resistance, difficulty swallowing, drooling, etc.:
Developmental Milestones Please note the age the following was achieved. If unsure of the age, check whether it was achieved Early, Late or within Normal limits.
Age Early Normal Late Rolled Over Sat without support Grasped pencil/crayon Crawled Stood up Walked holding on Walked without holding on Fed Self Dressed Self Tied shoes Pedaled tricycle Rode bike Swam Babbled Spoke first words Put two words together Spoke in short sentences
pg. 7
Language Development At what age was your child easily understood by others?
Please check any of the following items that relate to your child’s language: Often asks others to repeat what they have said
Repeats sounds, words or phases over and over
Unable to understand what you are saying
Names things around the house and/or people
Unable to follow one step directions
Mispronounces words or leaves off sounds in words
Unable to follow multi-step directions
Leaves off small words (the, is, to) when speaking in sentences
Unable to remember short messages
Leaves off endings (plurals, -ed) when speaking in sentences
Unable to respond correctly to yes/no questions
Child avoids being read to
Unable to respond correctly to who/what/where/when/why questions
Gets frustrated when explaining things orally
Has a hard time expressing his/her ideas
Trouble finding words he/she wants to use
Has a hard time asking for help/making his/her wants and needs known to others
Talks around an issue without coming to the point
Child does not enjoy listening to stories
Is your child’s speech: Usually loud Filled with “um and “you know” Usually soft Unable to be understood by
familiar others
Hoarse, breathy, or strained-sounding
Unable to be understood by unfamiliar others
Dysfluent
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Your child currently communicates using: Body language
Single words
Sounds (vowels and vocalizations)
2 to 4 word sentences
Has your child ever had Speech Therapy? If yes, please specify where, when and goals at that time or currently:
Yes No
Sensorimotor Development Please check any of the following items that relate to your child’s sensory and motor skills Tactile (Touch) Muscle Tone
Has trouble managing personal/physical space
Slouches when sitting on floor/chair
Over sensitive to clothing /textures/foods
Gets tired easily playing and writing
Under sensitive to clothing/textures/foods
Seems generally weak compared to others
Visual Vestibular(Movement) Has passed most recent vision screening
Loses balance easily
Has trouble tracking objects with eyes
Likes rough housing, jumping, crash games
Avoids eye contact with others Gets carsick easily Has trouble copying words from the board
Prefers to be sedentary (on computer/TV) rather than play outside
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Auditory(Sound) Taste & Smell Has passed most recent hearing screening
Picky eater
History of PE tubes in his/her ears Has trouble eating different texture foods
History of frequent ear infections Sensitive to noxious smells/tastes Sensitive to loud sounds (school bells, sirens)
Insensitive to noxious smells/tastes
Fails to listen, or pay attentions to what is said to him/her
Prefers spicy, sour bitter food flavors
Has difficulty if 2 or 3 step instructions are given at once
Talks excessively/not wait his/her turn
Coordination
Has difficulty with sequential tasks; dressing, buttoning Has difficulty playing on playground equipment Has difficulty holding a pencil or crayon in a 3-point position Does not enjoy sports Poor ball skills for P.E type activities Seems clumsy, awkward Bumps onto furniture, people often Left Handed Right Handed Mixed hand preference/Ambidextrous Poor Handwriting Has trouble using both hands together easily (opening milk carton, water bottle, etc.)
Cannot ride a bike Cannot tie shoelaces
Sleep
What time does your child go to sleep (PM)? What time does your child wake up (AM)?
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Please check any of the following items that relate to your child’s sleep
Difficulty staying asleep
Sleep walking
Difficulty falling asleep Nightmares Frequent wakening Recurrent Nightmares
Please describe any past or present concerns/difficulties regarding your child’s sleep patterns:
Toileting Please note when the following milestones were achieved
Age Early Normal Late Trained for Urine Trained for Bowels
Please check off any of the following difficulties that relate to your child’s toilet training
Bed Wetting after training Urine accidents during the
day
Night time soiling after training
Soiling during the day
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Current Behavior
Please check any of the following items that relate to your child’s current behavior
Shy Noise or Touch Sensitivity Difficulty listening Immature Tics and twitching Gets easily frustrated Well behaved Always in motion Has poor self-esteem Stubborn Excessively fidgety Fears making mistakes Impulsive Difficulty paying attention Eats paper, paints, etc Temper tantrums Difficulty staying at one
task for a long time Moods change quickly
Cries excessively Gets distracted while watching TV
Difficulty understanding jokes
Tells lies Difficulty with transitions Self-abusive behavior Thumb sucking Difficulty with finishing a
task Withdrawn
Head banging Disorganized Stubborn Nail biting Shows poor judgment in
dangerous or questionable situations
Plays alone for a reasonable length of time
More active than others
Poor awareness of time Poor eye contact
Clumsy using hands Gets lost easily Cooperative Poor handwriting Frequent Accidents Attentive Clumsy walking Destructive/Aggressiveness Willing to try new
activities
Blank spells or Fainting spells
Were any of the above significant issues which have gone away? If so, please explain:
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Medical History
Please describe any hospitalization or injuries your child may have had:
Please report any medical diagnosis or conditions:
Please indicate if your child experienced any of the following conditions and the age when the condition occured Age Age Adenoidectomy Diabetes Tonsillectomy Asthma Braces or other orthodontic appliances
Head injuries which require medical attention
Ear Infections Seizures Ear Tubes Allergies Meningitis Loss of consciousness Encephalitis Heart defects
Please check if your child complains of any of the following conditions, and note how frequent the complaints occur Check Frequency Check Frequency Headache Stomachache Nausea Aches or pains Vomiting Trouble with hearing Weakness Chronic constipation Dizziness Trouble with vision
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Please list all the PREVIOUS medications that were taken for more than one month Name Dose Reason Given
Please list all the CURRENT medications Name Dose Reason Given
Vision Visual Defects? Glasses? If Yes, for what reason?
Yes No
Date of last vision screen: What were results?
Hearing Hearing Problem? If Yes, for what reason?
Yes No Date of last hearing screen? What were results?
Please explain if you consulted with any other medical specialist for your child?
Does your child have a diagnosis from a pediatrician, psychologist, psychiatrist or other professional? If yes, please describe:
Has child received any psychological or psychiatric treatment? If yes, please describe. Were improvements noted?
pg. 14
Has the child ever experienced any parental separations, divorce, or death? Yes No
If yes, when? How old was the child at the time?
Please describe the circumstances:
Does the child have trouble separating now?
Educational History
Child Attended Nursery School:
Child Attended Kindergarten:
What, if any, problems were reported?
List all prior schools attended and years of attendance:
Current School, Address and Teachers Name: Phone Number:
Describe any problems at School
Retentions (Grade)
Suspensions
Regular Classroom
Special Ed/Placements (Include Age placed in Special Education)
Please describe any private support/services your child receives and noted improvements:
What are your child’s strengths and/or best subjects?
pg. 15
School psychological testing was completed?
Testing results (please provide copies of previous testing):
Yes No
Is your child having difficulty with any subjects?
Describe your child’s attitude towards school:
Has your child ever missed an extended amount of school? If yes, please explain:
Please check any of the following items that relate to your child’s current behavior
Reading Social Adjustment Following Directions Spelling Attention Span Getting along with other
children
Math Distractibility Getting along with teachers Writing Hyperactivity Does not complete homework
readily
Behavior Difficulty paying attention
Has your child had any of the following evaluations performed in school or privately? Please provide copies of any prior test
Name of
Evaluator Date of Evaluation
Findings
Physical Therapy Occupational Therapy Speech and Language Audiology Psychology Neurology Other Has your child received any of the therapies listed above in school or privately? Please explain:
pg. 16
Social Emotional Development
Describe your child’s current social skills and peer relationships. Please note if your child has a history of being bullied/teased or has been aggressive in play with others.
How would you describe your child socially? How do you think your child interacts with peers while at school?
Does your child have a best friend? Does your child have difficulty keeping friends?
Yes No Yes No
What special interests does your child have?
Please list your child’s favorite hobbies, activities, games and other sports (e.g. piano, books, dolls, crafts, etc.) Also, please describe how well you feel your child does in these areas:
Which sports does your child most enjoy playing? Describe how well your child does in these sports compared to peers?
Please list any additional organizations, clubs, teams, or groups in which your child participates:
How does your child handle stress?
What are your child’s strengths?
In what areas would you like to see your child stronger?
Any other pertinent information that you would like to share?
pg. 17
Family History
Year Length of Pregnancy
Birth Weight Sex Complications Mother’s Age
Hospital where born
Family Intact Single Parent Divorced Remarried Name, ages, and gender of household members and family living in the home:
Name, ages, and gender of household members and family living outside the home:
Who is the child’s primary caregiver? Who cares for the child when the primary caregiver is away?
Please check off family members who reside in the child’s home and list each person’s name and age:
Living at
home Name Age
Mother Father
Siblings
Siblings
Siblings
Siblings
Other
Mother Living Deceased Age Birth Place
Highest Grade Completed: Current Employment How many hours away from home perday?
pg. 18
Father Living Deceased Age Birth Place
Highest Grade Completed: Current Employment: How many hours away from home per day?
Family Relations
Are there significant marital conflicts? If yes, briefly describe:
Yes No
Is there conflict between child and parents? If yes, briefly describe:
Yes No
Is there conflict between siblings? If yes, briefly describe:
Yes No
Who disciplines the child and how? Do parents agree on discipline? Yes No
Does your child have difficulty getting along with adults? Does your child have difficulty getting along with siblings?
Describe your child’s relationship with his/her siblings:
Describe your child’s relationship with his/her parents:
Please check the activities in which the child participates with the family: Movies Sports Church Visits with relatives Meals Trips Games Television Conversation Other
pg. 19
Family Medical History
Please check off whether any family members have a history of any of the following condition. If yes, please note the child’s relation to the family member with the condition
History Relationship History Relationship
Attention Deficit/ Hyperactivity
Developmental Delays
Depression Bed Wetting/Bowel Movements Withholding
Anxiety Neurological disease
Substance Abuse/Dependency
Seizures
Autism/Pervasive Developmental Disorders
Hearing Problems
Learning Problems or Learning Disabilities
Mental Retardation
Slowness in Walking
Psychiatric Hospitalization
Slowness in talking Difficulty with Law
Speech Problems Other (Specify)
Form Completed by (Please Print) Relationship to Child Date
Please submit this and other required forms to The Southfield Center for Development in one
of the following ways:
1. Click the PRINT BUTTON below, print the document, and bring the document directly to the center.
2. Click the SAVE BUTTON below, save the document, and e-mail the document
3. Click the SUBMIT BUTTON below and automatically e-mail the document. [NOTE THAT this only works in the Internet Explorer and Microsoft Edge
browser.
Thank you!
