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FORMS

Child Background Form

CHILD BACKGROUND FORM

This information you give below is for professional use only.
Note: The following form is likely to take 30-60 minutes to complete. Before beginning, please scroll through the form to make sure you have access to the necessary information (the form must be completed in one sitting).

Parent/Custodial Caretaker #1
Parent/Custodial Caretaker #2

If applicable

If applicable

Please CHECK any of the following which are problems for your child.

BIO-MEDICAL AND DEVELOPMENTAL HISTORY

At what age did your child:

Medications: please list the following information for all medications and/or supplements taken

SCHOOL HISTORY

Current homeroom teacher

Child’s school performance

**PLEASE BRING COPIES OF PRIOR EVALUATION REPORTS IF YOU HAVE ANY**

FAMILY HISTORY

Were they any previous marriages for the father?

Were there any previous marriages for the mother?

Any subsequent marriages for the father?

Any subsequent marriages for the mother?