CHILD DEVELOPMENTAL QUESTIONNAIRE-R

Mitchell Rosen, LMFT

43537 Ridge Park Drive

Temecula, CA 92590

(951) 541-3158

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:

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:

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:

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

Child Developmental History

Childhood History