CHILD DEVELOPMENTAL QUESTIONNAIRE-R

Mitchell Rosen, LMFT

43537 Ridge Park Drive

Temecula, CA 92590

(951) 541-3158
Child Developmental History

Use Separate Form for Each Child
Full Name of person completing this form:

First NameLast Name
Relationship to Child
If other, explain:
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Name, Address, and Phone Number of School including teacher and grade
Child is presently living with:

Natural MotherNatural FatherStepmotherStepfatherStep-Parent without marriageAdoptive MotherAdoptive FatherFoster ParentGuardianOther
If other please explain
Name and relationship of every person living in the home with the child(ren):
Please state in detail any concerns you have about each child's emotional and/or physical health:
Childhood History
Please explain if there were any complications with pregnancy or bith?
If child was adopted, what were the circumstances, age of child at adoption, and date of adoption?
At what age was child toilet trained and were there any problems?
At what age did child begin to speak and were there any problems with speech?
To the best of your knowledge, did the biological mother use alcohol or drugs during pregnancy?
Please list names, ages, and addresses of all siblings:
To the best of your knowledge did the biological father use alcohol or drugs?
Please list child's present height and weight
Date of most recent medical exam and findings:
Please list name, phone number, and contact information for this child's pediatrician:
Does the child currently take any medications? If so, for what condition and what is the dosage and frequency?
Is the child current with all immunizations? Why or why not?
Date of last dental exam and contact information for dentist?
Has the child had any serious illnesses or injuries? If yes, please explain in detail:
Does the child wear any prosthetic devices including hearing aids, braces, glasses, or contact lenses?
Does the child have any speech or hearing problems? If yes, please explain in detail:
Please mark if the child has ever had issues with:

SeizuresNightmares or Night TerrorsBed WettingSoilingExcessive Nervousness or CryingRockingSleep WalkingStuttering or StammeringTics (involuntary movements)Angry Outbursts or Problems with AngerNail BitingHair PullingObsessive or Repetitive BehaviorsDifficulty Making or Keeping FriendsDifficulty Expressing or Receiving AffectionAbuse physical, psychological or sexualAbusing others
Could you please describe your child's connection/bonding with both parents, guardians and/or caretakers?
Any additional issues or concerns not listed above:
How would you describe your child's physical health, please be detailed:
Has your child ever received counseling or therapy or been recommended for either? Please describe in detail including reasons, provider, contact information for provider, frequency and if it is still ongoing?
How old was your child when they entered school?
Have any teachers or administrators expressed concerns about your child and what were they?
Has your child ever skipped a grade or been retained? At what age and what was the reason?
Has your child ever been on a 504 or IEP for school and what were the reasons?
I hereby swear under penalty of perjury the facts contained in this questionnaire are true and accurate to the best of my recollection.
Electronic Signature
Date
Case Name
Should be Empty:

Child Developmental History

Childhood History