Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form Page 3
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5During the pregnancy
Did the mother take medication? o No o Yes - What kind? _ __________________________________________
Did the mother smoke? o No o Yes - How many cigarettes each day? __________________________________
Did the mother drink alcoholic beverages? o No o Yes - How frequently? o Daily o Weekly o Monthly
Did the mother use drugs? o No o Yes – What kind (specify) _ _________________________________________
How frequently? o Daily o Weekly o Monthly.
Was your child premature? o No o Yes - how early? (e.g. 4 weeks) _______________________________________
Was a Cesarean section performed? o No o Yes - for what reason? _______________________________________
Were there any birth defects or complications? o No o Yes - please describe _______________________________
At birth, was your child’s weight
o less than 6lbs o between 6lbs and 9lbs o more than 9lbs
All children develop at different rates. We would like to learn about your child’s early development. Please check any of
the boxes below if you viewed your child’s development, in that area, as delayed or a cause for concern.
o Rolling over
o Sitting alone
o Crawling
o Standing alone
o Walked alone
o Sleeping through the night
o Spoke first word
o Put several words together
o Toilet training
o Colicy/Fussy
o Feeding/Eating
o Other development/growth issues
Please explain any checked boxes above. _____________________________________________________________
Has your child ever had any speech problems? o No o Yes - please describe _______________________________
Has your child previously received speech/language therapy?
) o Yes (Outside agency/doctor) o Yes (other) _ _______________
o No o Yes (by SBCSC) o Yes (by FirstSteps/
SNAP
_______________________________________________________________________________________________
Please list any past injuries, serious illnesses, or surgeries your child has had. please note the approximate date (or
child's age at the time) _ ___________________________________________________________________________
_______________________________________________________________________________________________
Has your child ever been hospitalized? o No o Yes If yes, indicate reason, length of stay and approximate age of the
child __________________________________________________________________________________________
Has your child ever experienced seizures? o No o Yes If yes, please describe _______________________________
_______________________________________________________________________________________________
Has your child received outside professional services? (use a P for past, C for current)
__ Counseling
__ Skills Trainer
__ Case Manager __ Probation Officer __ Tutoring
__ Mentoring
__ DCS Case Manager __ Occupational / Physical Therapy
__ Other (Specify) ___________________________
Provide any other helpful information about these services (names, dates, reasons): _________________________
_______________________________________________________________________________________________
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S
P
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8/2016
ARENT
URVEY
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