intake packet checklist children over 5 years 1 intake packet checklist children over 5 years please...

INTAKE PACKET CHECKLIST Children over 5 years

Please complete all relevant questions on the Intake Form. Please complete and sign the Insurance Information/Authorization of the Intake Questionnaire. If you have copies of any recent evaluations (psychological, developmental testing, speech/language, hearing, vision), please include them when you send us your Intake Form. Please include copies of your child’s IEP and/or the results of any school testing/evaluations. If you are the child’s guardian and not the birth or adoptive parent, please include copies of the Guardianship papers (court order or Power of Attorney) with your Intake Form. If your child is in a school, preschool, or daycare setting, please have his or her teacher(s) fill out the Educational Questionnaire and send it back to us. If you need help in filling out the Intake Form, please call (205) 638-2294 and we will help you with your questions.

Please return all Intake materials by mail or fax to:

Developmental Medicine Clinic 1600 7th Avenue South

Dearth Tower Suite 5602 Birmingham, AL 35233 Phone: (205) 638-2294

Fax: (205) 212-2994 We look forward to working with you and your family. If you do not hear from us 2 weeks after sending the packet to us, please call the number above to make sure we have received your packet. Thank you, The Developmental Medicine Clinic Children’s of Alabama

Developmental Medicine Clinic

Children over 5 years (rev. 2016-11-21)

About Your Child:

Name:___________________________________________________________________________ Last First MI Nickname Date of Birth:___________________ Gender: Male Female Race:______________ Address:_________________________________________________________________________ Street Apt or Unit # City State Zip Code County

Reason for Coming to Clinic:

What three specific questions about your child’s development or behavior would you like to ask us? 1)____________________________________________________________________________ 2)____________________________________________________________________________ 3)____________________________________________________________________________ Who referred you to us? ___________________________ _____________________________ _________________ Name Organization Phone Number _______________________________________________________________________________ Primary Medical Provider (if different from above) Location Phone Number

Important Information: What languages do you speak at home?_______________________________________________

Do you or your child need an interpreter for your visit? ☐Yes ☐No

Do you or your child need any special assistance for your visit? ☐Yes ☐No If yes, describe:

________________________________________________________________________________ ________________________________________________________________________________

Your Contact Information: Parent/Caregiver 1: Name:_________________________________________________ Last First Relationship to child:______________________________________ Legal Guardian? Yes No Address:_________________________________________________________________________ Street Apt or Unit # City State Zip Code County Main Phone:________________ Alternate Phone:_______________ E-mail Address:_________________________________ Parent/Caregiver 2: Name:_________________________________________________ Last First Relationship to child:______________________________________ Legal Guardian? Yes No Address:_________________________________________________________________________ Street Apt or Unit # City State Zip Code County Main Phone:________________ Alternate Phone:_______________ E-mail Address:_________________________________ Legal Guardian (if different from above): Name:_________________________________________________ Last First Relationship to child:______________________________________ Address:_________________________________________________________________________ Street Apt or Unit # City State Zip Code County Main Phone:________________ Alternate Phone:_______________ E-mail Address:_________________________________

Pregnancy & Birth: Check if birth history is not known.

Was your child born on time? Yes No Number of weeks:______ At the time of birth, how old was: Mother:_______ Father:________ How many times has mother been pregnant before this child?_____ How many: Miscarriages?___ Abortions?____ Stillbirths?____ Any problems during pregnancy? Yes No If yes, please explain:_______________________________________________________________ ________________________________________________________________________________ During pregnancy, did mother take: Prescription medications?____________________________________________________________ Vitamins or supplements?____________________________________________________________ Drugs? Yes No If yes, list:________________________________________________ Smoke? Yes No If yes, how many packs a day?____________ Drink alcohol? Yes No If yes, how much?__________________________________________ Where was baby born?______________________________________________________________ Name of Place City State Was the baby born: Naturally (vaginally) C-section If C-section, why?__________________________________________________________________ Any problems during delivery? Yes No Apgars (if known)? ___1 min ___5 min If yes, please explain:_______________________________________________________________ ________________________________________________________________________________ How long did baby stay in the hospital?___________ Which hospital?________________________ Any medical problems while in the hospital?

Breathing problems Heart problems Brain problems Eye problems Feeding problems Infections Stomach problems Skin problems

If any problems, please explain:_______________________________________________________ ________________________________________________________________________________ Birth weight:___________ Birth length:___________ Head circumference:____________ Was baby: Breastfed Bottle fed If breastfed, for how long?_____________

Your Child’s Development:

When did your child first:

Not Yet Early On Time Late If known, at what age?

Roll over? Sit without support?

Crawl? Walk?

Say first words? Put two words together?

Say whole sentences? Become dry during day?

Become dry at night? Become bowel trained?

How old was your child when you first became worried about his/her development? ___________ What worried you at that time?_____________________________________________________ Did your child ever stop doing any skills that he/she had learned? Yes No If yes, please explain:_______________________________________________________________ How does your child communicate (check all that apply)?

Crying/Whining Single words Electronic devices/tablets Sign language Playful sounds Short phrases Picture communication boards Facial expressions Pointing Sentences Grabbing/Using your hand

Are you worried about your child’s social or play skills? Yes No If yes, please explain:_______________________________________________________________ ________________________________________________________________________________ Are you worried about your child’s: Toileting? Yes No If yes, explain:____________________________________________ Feeding? Yes No If yes, explain:____________________________________________ Sleep? Yes No If yes, explain:____________________________________________ Please tell us what your child is good at doing. What are his/her strengths?_____________________ ________________________________________________________________________________ Please tell us what your child likes to do for fun or play with:_________________________________ ________________________________________________________________________________

Your Child’s Behavior:

Circle the number that best describes your child’s behavior OVER THE PAST 6 MONTHS

Never or Rarely

Occasionally Often Very Often

1. Fails to give close attention to detail or makes careless mistakes (e.g. homework)

0 1 2 3

2. Has difficulty attending to what needs to be done 0 1 2 3

3. Does not seem to listen when spoken to directly 0 1 2 3

4. Does not follow through when given directions 0 1 2 3

5. Has difficulties organizing tasks and activities 0 1 2 3

6. Avoids, dislikes, or does not want to start tasks 0 1 2 3

7. Loses things necessary for tasks or activities (school assignments, books, pencils, etc.)

0 1 2 3

8. Is easily distracted by noises or other things 0 1 2 3

9. Is forgetful in daily activities 0 1 2 3 Office Use Only (I) (1-9)___/9 > 6/9 SUBTOTAL:______

10. Fidgets with hands or feet or squirms in seat 0 1 2 3

11. Leaves seat when he/she is supposed to stay in seat 0 1 2 3

12. Runs about or climbs too much when he/she is supposed to stay seated

0 1 2 3

13. Has difficulty playing or starting quiet games 0 1 2 3

14. Is “on the go” or acts as if “driven by a motor” 0 1 2 3

15. Talks too much 0 1 2 3

16. Blurts out answers before questions have been completed

0 1 2 3

17. Has difficulty waiting his/her turn 0 1 2 3

18. Interrupts or bothers others when they are talking or playing games

0 1 2 3

Office Use Only (HI) (10-18)___/9 > 6/9 SUBTOTAL:______

19. Argues with adults 0 1 2 3

20. Loses temper 0 1 2 3

21. Actively disobeys or refuses to follow adult’s request or rules

0 1 2 3

22. Bothers people on purpose 0 1 2 3

23. Blames others for his or her mistakes or misbehaviors 0 1 2 3

24. Is touchy or easily annoyed by others 0 1 2 3

25. Is angry or bitter 0 1 2 3

26. Is hateful and wants to get even 0 1 2 3 Office Use Only (ODD): (19-26)/8 > 3/8


Never or Rarely


27. Bullies, threatens, or scares others 0 1 2 3

28. Starts physical fights 0 1 2 3

29. Lies to get out of trouble or to avoid jobs (i.e. “cons” others)

0 1 2 3

30. Skips school without permission 0 1 2 3

31. Is physically unkind to people 0 1 2 3

32. Has stolen things that have value 0 1 2 3

33. Destroys others’ property on purpose 0 1 2 3

34. Is physically mean to animals 0 1 2 3

35. Has set fires on purpose to cause damage 0 1 2 3

36. Has broken into someone else’s home, business, or car 0 1 2 3

37. Has stayed out all night without permission or run away from home overnight

0 1 2 3

38. Has used a weapon that can cause serious physical harm (e.g. bat, broken bottle, brick)

0 1 2 3

Office Use Only (CD): (27-38) ___/12 >3/12

39. Is fearful, anxious, or worried 0 1 2 3

40. Is afraid to try new things for fear of making mistakes 0 1 2 3

41. Feels useless or inferior 0 1 2 3

42. Blames self for problems, feels at fault 0 1 2 3

43. Feels lonely, unwanted, or unloved; complains that “no one loves me”

0 1 2 3

44. Is sad or unhappy 0 1 2 3

45. Feels different and easily embarrassed 0 1 2 3

46. Is overly concerned about health/body 0 1 2 3 Office Use Only (Anx/Dep): (39-46)___/8 > 3/8

47. Has problems getting along with parent(s) 0 1 2 3

48. Has problems getting along with others his/her own age 0 1 2 3

49. Has problems getting along with his/her own siblings 0 1 2 3

50. Has problems in group activities such as games or team play

0 1 2 3

Office Use Only (Soc): (47-50)___/4 > 1/4

51. Decreased interest in pleasure in all, or almost all, activities of the day

0 1 2 3

52. Has said things like “I wish I were dead” or has tried to hurt self

0 1 2 3

53. Recurrent excessive distress when separation from home or caretakers

0 1 2 3

54. Has distinct periods of unusually irritable or unusually cheerful mood (different from normal)

0 1 2 3

55. Has prolonged temper tantrums (greater than 20-30 minutes)

0 1 2 3

56. Hears voices others do not hear 0 1 2 3

57. Has compulsions (e.g. child seems driven to wash hands, count, erase until holes appear)

0 1 2 3


Never or Rarely


58. Has obsessions (e.g. persistent or repetitive distressing thoughts: germs, doors left unlocked)

0 1 2 3

59. Has recurrent recollections or dreams of a traumatic event

0 1 2 3

60. Seems to avoid or have phobias of specific people, animals, things, or situations

0 1 2 3

61. Seems unaware of others’ existence, is uninterested in interacting with others

0 1 2 3

62. Has odd, eccentric, or unusual preoccupations (e.g. clothing items, toys, neatness)

0 1 2 3

63. Appears uninterested in activities children his or her age usually like or participate in

0 1 2 3

64. Has experimented with or abused drugs or alcohol 0 1 2 3 Office Use Only (MH): (51-64)___/14 > 0

Other concerns:

What do you do when your child gets in trouble?

Time Out Spanking Yell at him/her Take away something fun Other:________________________________________________________________________

Does what you do usually help? Yes No

Your Child’s School:

School Name:___________________________________________ Grade:___________________ Main Phone:________________ Fax:_______________ Does your child have an Individualized Education Plan (IEP)? Yes No Does your child have a 504 Plan? Yes No Please list all services (physical therapy, occupational therapy, speech, ABA, etc.) that your child receives in school:__________________________________________________________________ Does your child receive services outside of school? Yes No If yes, please list all services and where:________________________________________________ ________________________________________________________________________________

Please circle the number that best describes your child’s current performance at school, or check “not applicable.”

Not applicable

Excellent Above Average

Average Somewhat of a

problem

Problematic

1. Overall school performance 1 2 3 4 5 2. Completing classroom assignments

1 2 3 4 5

3. Completing homework 1 2 3 4 5 4. Getting homework to and from school

1 2 3 4 5

5. Organizational skills 1 2 3 4 5 6. Reading 1 2 3 4 5 7. Spelling 1 2 3 4 5 8. Mathematics 1 2 3 4 5 9. Science 1 2 3 4 5 10. Written Expression 1 2 3 4 5 11. Handwriting 1 2 3 4 5

How does your child get along with other children at school?_________________________________ ________________________________________________________________________________ How is your child’s behavior at school?_________________________________________________ ________________________________________________________________________________ Any other information that you would like us to know about how your child does at school?_________ ________________________________________________________________________________ ________________________________________________________________________________ Has your child had any previous evaluations for concerns about development, behavior, or school? _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________

Please include a copy of your child’s most recent IEP and any reports from previous evaluations along with this paperwork.

Your Child’s Medical History:

Please tell us whether your child has problems now or in the past with:

If yes, please explain:

Eyes/Vision ☐Yes ☐No ☐Don’t Know

Ear, Nose, Throat ☐Yes ☐No ☐Don’t Know

Hearing ☐Yes ☐No ☐Don’t Know

Stomach/Intestines/Bowels ☐Yes ☐No ☐Don’t Know

Heart problems ☐Yes ☐No ☐Don’t Know

Heart rhythm problems ☐Yes ☐No ☐Don’t Know

Lung/Breathing problems ☐Yes ☐No ☐Don’t Know

Blood problems (anemia, leukemia, etc.) ☐Yes ☐No ☐Don’t Know

Brain/Neurologic problems ☐Yes ☐No ☐Don’t Know

Muscle or movement problems ☐Yes ☐No ☐Don’t Know

Skin problems ☐Yes ☐No ☐Don’t Know

Thyroid problems ☐Yes ☐No ☐Don’t Know

Diabetes ☐Yes ☐No ☐Don’t Know

Other endocrine/hormone problems ☐Yes ☐No ☐Don’t Know

Joint or bone problems ☐Yes ☐No ☐Don’t Know

Kidney problems ☐Yes ☐No ☐Don’t Know

Genetic or hereditary problems ☐Yes ☐No ☐Don’t Know

Accidents or injuries ☐Yes ☐No ☐Don’t Know

Mental health/emotional problems ☐Yes ☐No ☐Don’t Know

Learning problems (dyslexia, etc.) ☐Yes ☐No ☐Don’t Know

Intellectual Disability/Mental Retardation ☐Yes ☐No ☐Don’t Know

Autism spectrum ☐Yes ☐No ☐Don’t Know

Attention deficit (ADHD, ADD) ☐Yes ☐No ☐Don’t Know

List surgeries or operations your child has had below: ☐None

Surgery type Which hospital? Date of surgery

Please list times your child had to stay in the hospital overnight: ☐None

Hospital name Why? Dates of hospital stay

Are your child’s shots up to date? ☐Yes ☐No (explain):__________________________________

Has your child ever had:

MRI or CT scan? ☐No ☐Yes (explain):_______________________________________________

Genetic testing? ☐No ☐Yes (explain):_______________________________________________

Hearing test by a hearing specialist? ☐No ☐Yes (explain):________________________________

Other procedures or medical tests? ☐No ☐Yes (explain):_________________________________

________________________________________________________________________________

Your Child’s Medications and Allergies:

Please list all medications your child takes now:

Name Dose How often? Date started Who prescribes? Does it help?

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

If you need more room, please write on a new sheet of paper. Please list all medications your child has taken in the past:

Name Dose How often? Dates taken Who prescribed? Did it help?

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

☐Yes ☐No

If you need more room, please write on a new sheet of paper. Please write any vitamins, herbals, or supplements your child takes below: ________________________________________________________________________________ ________________________________________________________________________________ Please list all allergies, including your child’s reaction (hives, trouble breathing, etc.), below: Food:____________________________________________________________________________ Medicines/Drugs:___________________________________________________________________ Environmental/Seasonal:____________________________________________________________

Does your child eat a special diet? ☐No ☐Yes (explain):_________________________________

________________________________________________________________________________ Please tell us other information about your child’s medical history that you think we should know: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

About the Family:

What is your child’s living/custody arrangement (check all that apply)?

☐Birth Mother ☐Birth Father ☐Guardianship ☐Foster Care ☐Adoptive Family

☐Other (explain):_________________________________________________________________

If child is in foster care or in an adoptive family, how old was the child when he/she came into your home?_________________ Please list everyone currently living in the child’s home, including you (use separate sheet if needed):

Name (first and last) Birthdate How related to child? Highest education Job/Work

Please list any birth parents and/or siblings not living in the child’s current home:

Name (first and last) Birthdate (or age)

How related to child?

Highest education

Job/Work Where does he/she live?

How often does your child get to see the other family members listed above who live elsewhere? ________________________________________________________________________________ Is there anything about your family’s religion, traditions, culture, or practices of your family that you would like us to know? ________________________________________________________________________________ ________________________________________________________________________________

Has the Department of Human Resources (DHR) ever been involved with your family? ☐Yes ☐No

If Yes, please explain:_______________________________________________________________ ________________________________________________________________________________

Family Medical History:

Please tell us whether any of the child’s biological family members has any of the following. Biological family members (related to the child by blood) include mother, father, grandparents, brothers, sisters, aunts, uncles, and first cousins.

Condition Mother’s Side Father’s Side

Who? And what problem? Who? And what problem?

Autism/Asperger’s/PDD

Developmental Delay

Learning Problems

Intellectual Disability (formerly mental retardation)

ADHD or ADD

Speech or language problems

Tics or other movements

Seizures/Brain problems

Severe emotional problems (depression, bipolar, etc.)

Anxiety

Schizophrenia or psychosis

Alcohol/drug problems

Stillbirths

Birth defects

Heart problems

Heart rhythm problems

Sudden, unexplained death

Diabetes

Thyroid problems

Hearing loss/problems

Eye problems

Genetic/Hereditary problems

Other:

Thank You! ___________________ ___________________ ____________________ Signature Printed Name Date Completed ___________________ Relationship to Child

Please return to:

Developmental Medicine Clinic 1600 7th Avenue South

Dearth Tower Suite 5602 Birmingham, AL 35233

Fax: (205)212-2994

Children’s Health System-Authorization for Release of Information

Patient Name (First, Last, MI):_________________________________________________________________

Address:__________________________________________________________________________________

Phone Number: (_____)____________________________Date of Birth:_______________________________

This Authorization applies to the following Information:

All Information. I understand that the information may contain psychiatric/psychological, alcohol/drug abuse, and/or HIV

information and I expressly consent to the release of the information.

Only the following records or types of Information: __________________________________________

_________________________________________________________________________________________

Treatment Dates: from (month/day/year) ______/______/______ to (month/day/year) ______/______/______

The Information may be released as follows:

by to (Please check all that apply)

X X Children’s Health System (Please provide address & phone number):Developmental Medicine Clinic,

1600 7th Avenue South, Dearth Tower, Suite 5602, Birmingham, AL 35233; (205)638-2294; FAX (205)212-2994

External Individual/Agency/Organization (Please provide address & phone number):________________

_________________________________________________________________________________________

Purpose of the release:

X Continuity of Treatment Other (Please specify):__________________________________________

I understand the Information released will be limited to information necessary to fulfill the need or purpose

for the disclosure. If I have authorized the disclosure of Information to a recipient who is not subject to the

Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), then the recipient may re-disclose it

and it may no longer be protected under HIPAA, a federal privacy law. This Authorization is valid for ninety

(90) days from the date of signature, unless otherwise noted. This Authorization only applies to treatment

occurring before the date of signature. I may decline to sign this Authorization. I understand I may revoke

this authorization in writing at any time by completing a form available from Medical Information Services. If

I revoke this authorization, the revocation will not apply to information that has already been released in

response to this authorization. I understand the patient’s health care and the payment for the patient’s

health care will not be affected if I do not sign this form. I understand I may see and copy the Information

described on this form if I ask for it, and I may receive a copy of this form after I sign it. Before requesting

medical record copies, please about the copy fee by law that may apply. I represent that I have the authority

to and voluntarily grant permission for the Information to be released as described above.

__________________________________ ____________________________________

Patient/Parent/Legal Guardian Printed Name Patient/Legal Guardian Signature Date

_________________________________________ ____________________________________________

Patient Signature (if 14 or older) Date Witness Signature Date

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DEVELOPMENTAL MEDICINE CLINIC EDUCATIONAL QUESTIONNAIRE (Over 5)

Child and Parent Information: Child’s Name: ___________________________________________________ Birth Date: _________________ Last First Middle Gender: Male Female Child’s Classroom/Age Level:___________________________________ Parent’s Name: ____________________________________Relationship to child:_______________________

Please have teacher(s) or child care personnel fill out and return. You may make copies if needed for more than one teacher. Form Completed by ______________________________________ Date Completed:______________

Position/Title_____________________________________________ How long have you known the child?__________________

Child Care/School:_______________________________________________________________________

Address: ________________________________________________________________________________ Street City State Zip County

Primary Phone:_____________________________Fax Number: _____________________________

What specific questions would you like answered that would help you better meet this child’s developmental and educational needs? 1) ________________________________________________________________________ 2) ________________________________________________________________________ 3) ________________________________________________________________________ Please describe the child’s strengths: Please describe any areas of functioning that need the most improvement: Any other specific concerns you have about this child? Besides English, are there any other languages used in the child’s instruction?

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Has the child ever been evaluated for learning or academic problems? ☐Yes ☐No

If yes, when?______ Please send copies of previous testing results and copy of the current Individual Educational Plan.

ACADEMIC PERFORMANCE: Please circle the appropriate number below.

Excellent

Above Average

Average

Somewhat of a

problem

Problematic

1. Reading decoding 1 2 3 4 5

2. Reading comprehension 1 2 3 4 5

3. Reading rate and fluency 1 2 3 4 5

4.Spelling accuracy 1 2 3 4 5

5.Mathematics concepts 1 2 3 4 5

6.Mathematics computation 1 2 3 4 5

7.Handwriting 1 2 3 4 5

8. Writing rate 1 2 3 4 5

9. Punctuation/grammar 1 2 3 4 5

10.Ability to express thoughts through writing 1 2 3 4 5

11.Gross motor skills 1 2 3 4 5

12.Fine motor skills (using pencil & scissors) 1 2 3 4 5

13.Overall school performance 1 2 3 4 5

CURRENT CLASSROOM BEHAVIOR: Please circle the appropriate number below.

Excellent

Above average

Average

Somewhat of a

problem

Problematic

1. Understanding verbal instructions 1 2 3 4 5

2. Completing classroom assignments 1 2 3 4 5

3. Organizational skills 1 2 3 4 5

4. Getting homework to and from school

1 2 3 4 5

5. Completing homework 1 2 3 4 5

6. Relationship with peers 1 2 3 4 5

7. Following directions 1 2 3 4 5

8. Disrupting class 1 2 3 4 5

9. Verbally participating in class 1 2 3 4 5

10. Written expression 1 2 3 4 5

11. Handwriting 1 2 3 4 5

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LEARNING PROBLEMS: Circle the number that best describes the child’s learning problems (I.e., above and beyond what would be expected for his or her developmental age) over the past 6 months. Never or

rarely Occasionally Often Very

often

1. Has trouble learning new material in an appropriate time frame for age and skills

0 1 2 3

2. Has little desire to master new skills 0 1 2 3

3. Unable to tell time, days of the week, months of the year 0 1 2 3

4. Can’t repeat information 0 1 2 3

5. Knows material one day; doesn’t know it the next 0 1 2 3

6. Has trouble holding several different things in mind while working

0 1 2 3

7. Has trouble following multi-step directions 0 1 2 3

8. Has difficulty copying written material from blackboard 0 1 2 3

Office Use Only (Gen): (1-8)___/8 >4/8

9. Difficulty orienting self (i.e., gets lost, can’t find way, or gets turned around easily

0 1 2 3

10. Has poor spatial judgment and often bumps into things 0 1 2 3

11. Confuses directionality (up/down, left/right, over under) 0 1 2 3

12. Has poor spatial organization on paper (difficulty staying in lines, maintain space between words, staying within page margins)

0 1 2 3

13 .Mixes up capital and lower case letters when writing 0 1 2 3

14. Reverses letters and numbers 0 1 2 3

Office Use Only (VSP): (9-14)__/6 >3/6

15.Has trouble expressing words or events in correct order 0 1 2 3

16. Often mispronounces known or familiar words or uses wrong word

0 1 2 3

17. Has trouble verbally expressing thoughts 0 1 2 3

18. Says things that have little or no connection to what others are discussing

0 1 2 3

19. Has difficulty distinguishing long vowel sounds and short vowel sounds

0 1 2 3

20. Depends on teacher or others for repetition of task instructions 0 1 2 3

Office Use Only (Lang): (15-20)__/6 > 3/6

21. Displays poor word attack skills (can’t sound out words) 0 1 2 3

22. Puts wrong number of letters in words 0 1 2 3

23. Confuses consonant sounds, e.g.: d-b, d-t, m-n, p-b, f-v, s-z 0 1 2 3

24. Unable to keep place on page when reading 0 1 2 3

Office Use Only (R/W): (21-24)___/4 >2/4

CLASSROOM SETTING: Please check all that apply, and provide details. Type of setting Number of students Number of instructors Aide present for child?

Mainstream 1:1 Shared None

Integrated 1:1 Shared None

Substantially separate

1:1 Shared None

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GENERAL EDUCATION SETTING: Please list any specific curricula or instructional methodologies used in the child’s general education setting, if applicable Academic area Methodology or curriculum

Reading/reading-related materials

Mathematics

Writing/written expression

Please list services child receives through IEP: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

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CHILD’S BEHAVIORAL AND EMOTIONAL FUNCTIONING Circle the number that best describes the child’s behavior OVER THE PAST 6 MONTHS Never or

Rarely Occasionally Often Very Often

1. Fails to give close attention to detail or makes careless mistakes (e.g. homework)

0 1 2 3

2. Has difficulty attending to what needs to be done 0 1 2 3

3. Does not seem to listen when spoken to directly 0 1 2 3

4. Does not follow through when given directions 0 1 2 3

5. Has difficulties organizing tasks and activities 0 1 2 3

6. Avoids, dislikes, or does not want to start tasks 0 1 2 3

7. Loses things necessary for tasks or activities (school assignments, books, pencils, etc.)

0 1 2 3

8. Is easily distracted by noises or other things 0 1 2 3

9. Is forgetful in daily activities 0 1 2 3

Office Use Only (I) (1-9)___/9 > 6/9 SUBTOTAL: _______

10. Fidgets with hands or feet or squirms in seat 0 1 2 3

11. Leaves seat when he/she is supposed to stay in seat 0 1 2 3

12. Runs about or climbs too much when he/she is supposed to stay seated

0 1 2 3

13. Has difficulty playing or starting quiet games 0 1 2 3

14. Is “on the go” or acts as if “driven by a motor” 0 1 2 3

15. Talks excessively 0 1 2 3

16. Blurts out answers before questions have been completed 0 1 2 3

17. Has difficulty waiting his/her turn 0 1 2 3

18. Interrupts or bothers others when they are talking or playing games

0 1 2 3

Office Use Only (H): (10-18) ___/9 > 6/9 SUBTOTAL:______

19. Loses temper 0 1 2 3

20. Actively disobeys or refuses to follow adult’s request or rules 0 1 2 3

21. Is angry or resentful 0 1 2 3

22. Is spiteful and vindictive 0 1 2 3

23. Bullies, threatens, or scares others 0 1 2 3

24. Initiates physical fights 0 1 2 3

25. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others)

0 1 2 3

26. Is physically cruel to people 0 1 2 3

27. Has stolen items of nontrivial value 0 1 2 3

28. Deliberately destroys others’ property 0 1 2 3

Office Use Only (ODD/CD) (19-28)/10 > 3/10

29. Is fearful, anxious, or worried 0 1 2 3

30. Appears self-conscious or easily embarrassed 0 1 2 3

31. Appears afraid to try new things for fear of making mistakes 0 1 2 3

32. Feels worthless or inferior 0 1 2 3

33. Blames self for problems, feels guilty 0 1 2 3

34. Feels lonely, unwanted, or unloved; complains that “no one loves me”

0 1 2 3

35. Appears sad, unhappy, or depressed 0 1 2 3

Office Use Only (Anx/Dep) (29-35) __/7 > 3/7

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Never or Rarely


36. Skips school without permission 0 1 2 3

37. Has set fires on purpose to cause damage 0 1 2 3

38. Destroys other’s property on purpose 0 1 2 3

39. Has broken into someone else’s home, business or car 0 1 2 3

40. Has said things like “I wish I were dead” or has tried to hurt self 0 1 2 3

41. Has distinct periods where mood is unusually irritable or unusually good, cheerful, or high which is clearly excessive or different from normal mood

0 1 2 3

42. Seems to have compulsions (repetitive behaviors that this child seems driven to carry out, such as repeated hand washing, counting, or erasing until holes appear)

0 1 2 3

43. Has prolonged temper tantrums (greater than 20-30 minutes) 0 1 2 3

44. Seems unaware of other’ existence, is uninterested in interacting with others

0 1 2 3

45. Has odd, eccentric, or unusual preoccupations (e.g., clothing items, toys, neatness)

0 1 2 3

46. Appears uninterested in activities children his or her age usually like or participate in

0 1 2 3

Office Use Only (MH): (35-46) ___/11 >/11

Please describe this child’s personality—moods, behavior, emotional functioning, etc. Please describe this child’s relationship with peers. Is there any other information you think would be helpful for evaluating this child? ___________________ _____________________ _________________________ Teacher Sign Print Date Completed ____________________ Relationship to Patient

Please send completed packet to: Developmental Medicine Clinic

1600 7th Avenue South Dearth Tower, Suite 5602 Birmingham, AL 35233

Fax: (205)212-2994

intake packet checklist children over 5 years 1 intake packet checklist children over 5 years please...

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