Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form Page 2
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Referral for Multidisciplinary Team Evaluation
Page
Describe your child’s typical routine in the morning prior to going to school (i.e. time awake? breakfast? any
difficulties getting ready for school/getting out the door? etc.) _______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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 (e.g., 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 ____________________________________________________________
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: ____________
__________________________________________________________________________________________
Rev. 6/12
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