Kerri Schneider, Ph.D., P.A.
Licensed Clinical Psychologist
Child Developmental History
Today’s date
Person(s) completing this form
Relationship to this child
IDENTIFYING INFORMATION
Child’s name
Birthdate
Sex ❑ Female ❑ Male
Age
Ethnicity
Primary Language
Secondary Language
Address
Mother’s name
Birthdate
Home phone
Work phone
Age
Cell phone
Address (if different from child):
Email address:
Occupation
Employer
How long with present employer
Highest grade completed
Primary Language
Secondary Language
Ethnicity
Religious/Spiritual Beliefs
Father’s name
Birthdate
Home phone
Work phone
Age
Cell phone
Address (if different from child):
Email address:
Occupation
Employer
How long with present employer
Highest grade completed
Primary Language
Secondary Language
Ethnicity
Religious/Spiritual Beliefs
8401 Lake Worth Road  Suite 219  Lake Worth, FL 33467
561.818.1640
Does this child have other parent(s)/stepparent(s)? ❑ No ❑ Yes If yes, please provide the following:
Stepparent’s name
Birthdate
Age
Relationship to child:
Home phone
Work phone
Cell phone
Address (if different from child):
REASON FOR REFERRAL
Why are you seeking help for this child?
Who referred you to my service?
FAMILY HISTORY
Has this child experienced parental separation, divorce, or death ❑ No ❑ Yes
If yes, when?
How old was this child at the time?
Please specify circumstances
If parents are separated or divorced, who has custody of this child?
How often does the other parent see this child?
RESIDENCES
Where was this child born?
Please identify all locations of residency for this child
Location
Dates of residency
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Reason for moving
Please list all siblings in addition to any other individuals living in the home
Age
Sex
Living at home?
FAMILY RELATIONS
How well does this child get along with parents?
How well does this child get along with siblings?
What do you enjoy most about this child?
What do you find most difficult about raising this child?
PREGNANCY
Complications during pregnancy? ❑ No ❑ Yes (if yes, describe)
Hospitalization during pregnancy? ❑ No ❑ Yes (if yes, describe)
Medications used during pregnancy? ❑ No ❑ Yes (if yes, describe)
Alcohol used during pregnancy? ❑ No ❑ Yes (if yes, indicate frequency)
Cigarettes used during pregnancy? ❑ No ❑ Yes (if yes, indicate frequency)
Other drugs used during pregnancy? ❑ No ❑ Yes (if yes, indicate kind and frequency)
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BIRTH
At this child’s birth, what was the mother’s age?
Length of pregnancy
Father’s age?
weeks
Birth Weight
lbs
oz
Child’s condition at birth
Mother’s condition at birth
Check any of the following complications that occurred during birth:
❑ Forceps Used
❑ Vacuum Extraction
❑ Breech Birth
❑ Labor Induced
❑ Caesarean Delivery (if yes, describe reason)
❑ Other Delivery Complications (if yes, describe)
❑ Incubator (if yes, how long?)
❑ Jaundiced: Bilirubin Lights? ❑ No ❑ Yes (if yes, how long?)
DEVELOPMENT
At what age did this child do each of these?
Turn over
Say first words
Sat without support
Put two words together
Crawl
Speak in sentences
Stand alone
Stayed dry all day
Walked without holding on
Stayed dry all night
Any problems during infancy (eating, sleeping, colic, etc)? (if yes, describe)
Any problems during child’s first 4 years (eating, sleeping, motor skills, separating from parents,
tantrums, excessive crying, etc)? (if yes, describe)
Any history of early intervention services, such as speech therapy, occupational therapy, or physical
therapy? (if yes, describe)
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HEALTH
Please list all childhood illnesses, hospitalizations, head injuries, important accidents and injuries,
surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions.
Condition
Child’s Age
Treatment/consequence?
Required hospitalization?
(if yes, how long)
Has this child ever been on any medication for 6 months or more? ❑ No ❑ Yes
If yes, when?
What kind?
Is this child currently taking any medications? ❑ No ❑ Yes
If yes, please indicate type and reason?
Does this child have any allergies? ❑ No ❑ Yes
If yes, please describe?
Are there any concerns regarding this child’s hearing? ❑ No ❑ Yes
If yes, please describe?
Are there any concerns regarding this child’s vision? ❑ No ❑ Yes
If yes, please describe?
Wears glasses or contacts? ❑ No ❑ Yes
Has this child ever had psychological counseling or therapy? ❑ No ❑ Yes
If yes, please indicate counselor’s name and duration of treatment?
Brief description of reason for treatment
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Has this child ever received psychiatric care? ❑ No ❑ Yes
If yes, please indicate doctor’s name and duration of treatment?
Brief description of reason for treatment
FAMILY HEALTH
Please provide health information for this child’s family members.
Condition
Family Member (M=mother, F=father,
S=sibling, MGP= maternal grandparent;
PGP=paternal grandparent, etc)
Attention Deficit Disorder
Yes
❑ No ❑
Anxiety
Yes
❑ No ❑
Depression
Yes
❑ No ❑
Bipolar Disorder
Yes
❑ No ❑
Learning Disability (specify type)
Yes
❑ No ❑
Alcohol/Drug Abuse
Yes
❑ No ❑
Speech/Language Problems
Yes
❑ No ❑
Autistic Spectrum Disorder
Yes
Medical Illness (specify)
❑ No ❑
Other Medical Illness (specify)
Other (specify)
SOCIAL HISTORY
Does your child have difficulty relating to or playing with other children? ❑ No ❑ Yes
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If yes, describe?
Fights frequently with playmates?
❑ No ❑ Yes
Has difficulty making friends?
❑ No ❑ Yes
Prefers to play alone?
❑ No ❑ Yes
What activities does this child enjoy?
Sports:
Hobbies:
Other:
Do you have concerns regarding your child’s emotions or behavior? ❑ No ❑ Yes
If yes, describe
EDUCATION
Name of Current School
Current Grade
Please describe most recent report card results
Does or did this child attend preschool/daycare? ❑ No ❑ Yes At what age?
Amount of time per day?
Days per week?
Any problems in preschool? ❑ No ❑ Yes If yes, describe?
Does or did this child attend kindergarten? ❑ No ❑ Yes
Any problems in kindergarten? ❑ No ❑ Yes If yes, describe?
Has this child changed schools for reasons other than normal academic progression? ❑ No ❑ Yes
If yes, when and why?
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Has this child been retained a grade in school? ❑ No ❑ Yes
If yes, when and why?
Has this child skipped a grade in school? ❑ No ❑ Yes
If yes, when and why?
Has this child been tested for special education? ❑ No ❑ Yes
If yes, when and why?
Is this child currently placed in a special education class? ❑ No ❑ Yes
If yes, what type of class?
Hours per day?
Does this child dislike going to school? ❑ No ❑ Yes
If yes, why?
Is this child absent from school frequently? ❑ No ❑ Yes
If yes, why?
Do you have any concerns about the quality of this child’s school or teachers? ❑ No ❑ Yes
If yes, describe?
ADDITIONAL COMMENTS
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