Referral For Multidisciplinary Team Evaluation (K-6) Form Page 2
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4Referral for Multidisciplinary Team Evaluation (K-6)
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Describe your child’s typical routine after school: ____________________________________________
_____________________________________________________________________________________
Describe your child’s typical homework routine (i.e. when/where, how long, how much assistance is needed,
etc)________________________________________________________________________ ______________
__________________________________________________________________________________________
What conditions at home could be influencing your child's behavior and/or achievement in school (i.e., marital
problems, conflicts, illness of family members)?
__________________________________________________________________________________________
Has your child received professional counseling? Yes
No _____
If yes, date of initiation
until _____________________
Name of agency
Therapist
Reason and Outcome ____________________________________________________________
B.
Developmental/Medical History
Does the mother have a history of any medical problems, drug or alcohol abuse, etc? Yes ______ No _______
If yes, please describe ________________________________________________________________
Does the father have a history of any medical problems, drug or alcohol abuse, etc.?
Yes ______ No _______
If yes, please describe ________________________________________________________________
During the pregnancy, was mother on medication? Yes
No ______
If yes, what kind? ___________________________________________
During the pregnancy, did mother smoke? Yes
No ______
If yes, how many cigarettes each day? ____________________
During the pregnancy, did mother drink alcoholic beverages? Yes
No _______
If yes, what did she drink? _____________________________________________
Approximately how much alcohol was consumed each day? ___________________
During the pregnancy, did mother use drugs? Yes
No ______
If yes, what kind? ________________________
How frequently? ________________________
Was your child premature? Yes
No
If yes, by how many months?_____________________
Was a Cesarean section performed? Yes
No _____
If yes, for what reason? _______________________________________________________________
What was your child's birth weight? ___________________
Were there any birth defects or complications? Yes
No
If yes, please describe: ____________
__________________________________________________________________________________________
The following is a list of infant and preschool behaviors. Please indicate the age at which your child first
demonstrated each behavior. If you are not certain of the age but have some idea, write the age followed by a
question mark. If you don't remember the age at which the behavior occurred, please write a question mark.
Behavior
Age
Behavior
Age
Sat alone
Put several words together
______
Crawled
Became toilet trained
______
Walked alone
Stayed dry at night
______
Spoke first word
______
Describe your child’s early language development: _______________________________________________
_________________________________________________________________________________________
Does your child have any speech problems? Yes____ No____ If yes, describe___________________________
Did your child previously receive speech/language therapy? Yes ____ No ____
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