Dr. Timothy King - Certified School Psychologist • Licensed Psychologist

Dr. Timothy L. King, Certified School Psychologist, Licensed Psychologist

Comprehensive Assessment Form

Dear Parents,
A comprehensive assessment of your child necessitates a thorough understanding of all background information relevant to your current concerns about your child. In preparation for your intake session, please complete this form either below or download it and mail to us as soon as possible.

You are welcome to fill out the form below with any comments, questions or requests. We look forward to hearing from you.

Date:

Child's name:

Birthdate: Age:

School:

Home address:

State:

Zip:

Home phone:

Business Phone:

(Mother) (Father)

Mother or Guardian:

Name:

Age:

Date of birth:

Employed:

Yes No

Occupation:

Employer:

Education:

(Highest grade/degree achieved)

Father or Guardian:

Name:

Age:

Date of birth:

Employed:

Yes No

Occupation:

Employer:

Education:

(Highest grade/degree achieved)

Is child living with both natural parents? Yes No

If not, please explaing:

If parents are separated/divorced, for how long have they been separated?

What is the child's relationship with non-custodial, natural parent? How often does the child see the non-custodial parent?

Social Development History

Brothers and/or Sisters

Name:

Sex: Age:

Grade/School/Occupation:

Name:

Sex: Age:

Grade/School/Occupation:

Name:

Sex: Age:

Grade/School/Occupation:

Other persons in the home (name, relationship and age):

Do you feel like your child is having difficulties at school? At home?

If so, what do you consider the problem?

When and how did the problem begin?

Are there any past or present circumstances which you think could be related to your child's present difficulties?

Comment on family relationships

Family History (check if any apply)

	Mother	Father	Siblings	Other Relatives
Learning Problems
Attention Problems
Emotional Problems
Substance abuse/addiction

Comments or explanations:

Child's History

Birth weight:

Months carried:

Hours in labor:

Mother's age at delivery:

Health during pregnancy:

Complications:

Please describe the child's general behavior, eating, sleeping as an infant and toddler:

Please provide approximate ages for the following

Sat up:		First words:		Toilet Trained:
Walked:		Sentences:

Health History

Date of last physical exam: Results:

Height:

Weight

Serious illness, injuries, hospitalizations, operations (please explain and include date)::

Please check any areas you think are a problem for your child (check if any apply):

Eating		Nightmares
Sleeping		Getting along with friends
Bedwetting		Overactive
Toilet problems		Self-help skills (dressing, bathing, etc)
Nail biting		Short attention span
Thumbsucking		Easily frustrated
Temper tantrums		Stealing
Lying		Fears
		Describe

Medical/Physical Conditions (check if any apply):

Asthma		Diabetes
Allergies		Tourette's Syndrome
Seizure Disorder		ADD/ADHD
Cerebral Palsy		Other
Chronic ear infections		Describe
Ear tubes

All children exhibit, to some degree, the following behaviors. Check those that you believe your child exhibits to an excessive degree compared to outhers his/her age:

Fidgets with hands, feet or squirms in seat

Has difficulty remaining seated when must do so

Easily distracted by extraneous stimulation

Blurts out answers to questions before they are completed

Difficulty paying attention during tasks or play activities

Shifts from one uncompleted activity to another

Has difficulty playing quietly

Often talks excessively

Interrupts or intrudes on others

Does not appear to listen to what is being said

Loses things necessary for activities

Boundless energy and poor judgment

Impulsivity/poor self control

Difficulty waiting turn

Fails to give close attention to detail

Difficulty organizing tasks

Acts like he or she is driven by a motor

Excessive number of accidents

Doesn’t seem to learn from experience

Avoids tasks that require a sustained mental effort

At what age(s) did you first notice these behaviors?

Has your child ever experienced or been witness to any traumatic experiences? If yes, explain.

Educational History

Has your child been involved in a preschool early intervention program? Explain.:

List schools attended by child (include nursery and kindergarten)(name, location, grade, reason for leaving)

Were you concerned about your child's ability to succeed in kargerten? If yes, explain.

Did your child attend pre-first? Repeated a grade?

Have your child's teachers ever complained about the following?

Doesn't still still in seat
Frequently gets up and walks around the classroom
Shouts out, doesn’t wait to be called on
Won’t wait his/her turn
Doesn’t cooperate well in group activities
Acts without thinking
Daydreams/lost in own thoughts
Doesn’t pay attention during large group lesson
Does better in one-to-one situations
Doesn’t respect the rights of others
Doesn’t complete work
Messy work
Comments:

Previous Evaluations (check those that apply, with dates and where it was done)

Psychological
Psychiatric
Speech/Language
Neurological
Other

Previous Therapy (check those that apply, with dates and where it was done)

Psychological
Psychiatric
Speech/Language
Neurological
Other

Reactions and Impressions

Describe your child's feelings about school:

How do you feel about your child's school?

Please list your child's major interests and hobbies

Friends:

How many male? What are their age ranges?

How many female? What are their age ranges?

Comments on peer relationships

We are interested in your comments and impressions about your child, please include child's strengths and weaknesses:

Mother's Comments:

Father's Comments:

Family doctor's name, address and phone number:

We thank you for assisting us in helping your child by completing this survey.

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