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Parent Questionnaire

Parent Questionnaire

(Please complete the form to the best of your ability and return it prior to your evaluation appointment. The evaluating therapist will review this form and may probe for additional information during the evaluation. Please include copies of related evaluations/progress reports and/or current IEP’s).
  • Specialized Therapy Services

  • Date Format: MM slash DD slash YYYY
  • Family Information and Background

  • Developmental Milestones

  • Please fill out, to the best of your knowledge, the month/year of age at which your child first accomplished the following:
  • Turned OverStood (Alone) 
  • Sat Alone1st Word 
  • CrawledWalked (Alone) 
  • Babbled2 Words Together 
  • Drop files here or
  • Birth History

  • Mother age at the time of pregnancy:Length of labor: 
  • Birth weight:Apgar score: 
  • Multiple births yes/noDid the mother recieve prenatal care? 
  • Current Speech - Language - Hearing

  • Feeding and Development

  • School Experiences

  • Scheduling

  • *Please include dates/times
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