Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form Page 2
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5Has the child been in foster care? o No o Yes. If yes, provide details
. ________
(when, why, how long and with whom)
_______________________________________________________________________________________________
If any brothers or sisters are living outside the home, list their names and ages _______________________________
_______________________________________________________________________________________________
Is there a history of learning and/or behavioral problems in the family? o No o Yes - specify ________________
_______________________________________________________________________________________________
TELL US ABOUT YOUR CHILD
What does your child like to do in his/her free time? _ __________________________________________________
What are some positive things about your child? _ _____________________________________________________
As a parent/guardian, what are your biggest concerns regarding your child's schooling and behavior? ____________
_______________________________________________________________________________________________
When did you first become concerned? ____________
What has helped? _______________
What makes the problem(s) worse? _____________
Quality of Sleep: o no problems o trouble falling asleep o trouble staying asleep o difficult to wake up
Explain above: _ _____________________________________________________________________________
Typical bedtime ________ Typical wake time _________ Does child take naps? o No o Yes
Describe the area where your child sleeps
__________________________
(room or type of area, alone or with others)
______________________________________________________________________________________________
In a typical day, how much time does your child spend in front of a screen
(TV, movies, video games, tablets, cellphones,
o less than 1 hr
o 1-2 hrs
o 3-5 hrs
o 6 or more hrs
computers)
When does your child use screens during the day
o before school o after school o right before bed
(check all that apply)
o weekends only o middle of night.
Have there been any recent changes to the student’s behavior/academics o No o Yes (describe) ______________
______________________________________________________________________________________________
Are there any conditions at home that could be influencing your child's behavior and/or achievement in school
(e.g.,
?
marital problems, exposure to violence, illness of family members, absent family members, financial stress etc )
______________________________________________________________________________________________
______________________________________________________________________________________________
TELL US ABOUT YOUR CHILD’S DEVELOPMENT & MEDICAL HISTORY
Biological Mother
Biological Father
o Medical Problems o Drug Abuse o Alcohol Abuse
o Medical Problems o Drug Abuse o Alcohol Abuse
o Unknown
o Unknown
If checked, specify ______________________________
If checked, specify _______________________________
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