WESTMORELAND INTERMEDIATE UNIT

102 Equity Drive  Greensburg, PA 15601

CONFIDENTIAL PARENT INPUT/ DEVELOPMENTAL HISTORY FORM

Student’s Name:______Sex:______

Date of Birth:______Home School:______

Current School:______Grade:______

Person completing form:______Relationship:______

Address:______Phone number:______

______

PARENT INFORMATION:

Child resides with (check all that applies):

____Mother____Father____Step-father _____Step-mother _____Other:______

Parents are (Check one): ____Married_____Separated _____Divorced

List ALL adults and children living within the home and their relationship to the child:

NAMEBirthdateRelationship

______

______

______

______

______

 Please list the primary language spoken in the home and indicate any cultural concerns that may affect your child’s learning.______

EDUCATIONAL INFORMATION:

Please complete the following information regarding your child’s school history. Please list the names of the schools your child has attended at each of these grade levels and add significant details about the child’s progress (e.g. social, academic, special instruction, testing, retention, etc…)

  • Preschool:
  • Kindergarten:
  • Grades 1 through 5
  • Grades 6 through 8
  • Grades 9 through 12

 Has your child received any type of remedial or special education programming, and if so, how long and by whom? (Please check all that apply)

Learning Support______

Emotional Support______

Speech and Language______

Student Assistance Program (SAP)______

Private Tutoring______

Title I______

IST______

Head Start______

Early Intervention______

Other math or remedial programs______

 Has your child ever been: (Please check)

Retained______

Number of retentions______

Suspended from School______

Number of Suspensions______

Expelled from School______

Number of expulsions______

 Please indicate the progress your child has experienced in school.

 Please list your child’s academic strengths and weaknesses.

 Please indicate those areas that you consider to be your child’s educational needs. (Please check)

Written Communication SkillsVisual Skills

____poor note taking skills____poor oral reader

____poor handwriting____poor writing and spelling

____poor written communication____reversals in reading or writing

____slow in completing assignments____trouble taking notes in content areas

Auditory SkillsOrganizational/Study Skills

____poor at following directions____poor work habits____unorganized

____poor verbal skills____fails to complete assignments____distractible

____reading and spelling problems____lacks motivation____short attention span

____poor speech/articulation skills____can’t get started or stay on task

Social Skills

____trouble with relationships____hyperactive

____disruptive____uncooperative

____discourteous___poor self-esteem

 Indicate those academic areas that you consider to be your child’s educational needs. (Please check)

Language ArtsReading

____poor expressive writing skills____poor phonics skills

____poor grammar and sentence structure____poor decoding

____poor capitalization and punctuation____poor comprehension, study skills

____poor spelling skills____avoids reading magazines, books, etc…

MathHistory

____does not know computation facts____has difficulty reading text and tests

____does not apply math skills for time, money, measurement____has difficulty understanding concepts

____does not understand word problems____poor recall of facts or events

____has difficulty with complex math processes

Science

____has difficulty reading text and tests

____has difficulty understanding concepts

____poor recall and application of content/skills taught

 Please describe any homework difficulties?

 Do you have any suggestions that would help the school in meeting your child’s educational needs?

BEHAVIORAL CONCERNS

 Please list any behavioral concerns.

 What strategies have been implemented to address these concerns? Were they successful?(Check all that apply)

Verbal Warnings______

Time Outs______

Removal of privileges______

Rewards______

Physical Punishment______

Agree with the child______

Avoidance of child______

 Please indicate how often your child does what he or she is told.

_____My child does what he/she is told to do-usually the first time.

_____My child needs to be reminded to do as told.

_____My child needs reminded frequently to get him/her to do what I say.

_____My child often refuses to do what he/she is told.

Comments:______

______

 Please list any concerns regarding your child’s social skills.

 Has your child received or is your child receiving mental health treatment? Is so, by whom, where, and how often?

_____Wrap-around (TSS, MT, BSC)____In-home

_____Outpatient____At a clinic

_____Family-based____In the hospital

____Other______

Comments:______

______

 Have any of the following stressful events occurred within the past 12 months?

_____Parents separated _____Death in family

_____Parents divorced_____Parent changed job

_____Family accident_____Changed schools

_____Family illness_____Family moved

_____Family financial problems_____Other (please specify)______

DEVELOPMENTAL HISTORY

 Please complete the following birth history.

  1. What was the mother’s age at child birth? ______
  1. During this pregnancy, did the mother experience any unusual illness, condition, or accidents? (for example, bleeding, Ph condition, Toxemia, Rh incompatibility, radium or x-ray, medication or treatment, falls, etc…) If so please describe: ______

______

______

  1. Length of pregnancy ______
  2. Length of labor ______
  3. Type of anesthetic ______
  4. What was the birth weight? ______lbs. ______oz.
  1. Delivery of baby:

____Normal____Forceps used

____Breech____Caesarean

____Induced

  1. Were there any complications during labor or during birth? ______

______

  1. Were there any unusual conditions immediately after birth? ______

______

 Please estimate as closely as you can the age (months or years) at which your child:

Sat up alone ______Crawled______

Stood holding onto support______Walked unsupported______

Spoke first words______Spoke simple sentences______

(other than “mama” or “dada”)

 Did your child have problems in feeding? ______Sleeping? ______

 If your child had or now has speech problems, please explain: ______

______

MEDICAL HISTORY

 Please complete the following medical history.

  1. Describe your child’s present condition of health: ______

______

  1. If the child has any physical handicaps, please describe fully: ______

______

  1. Has your child had any chronic health problems? (e.g. asthma, diabetes, heart conditions), if yes please explain. ______
  1. Has your child had any accidents, operations, or illnesses? (e.g. mumps, chicken pox, otitis media, pneumonia, seizures, head injury, severe bruises, broken bones, tonsils removes, tubes in ears, etc…) if yes please explain. ______

______

  1. How is your child’s:Hearing: ______Good ______Fair ______Poor

Vision: ______Good ______Fair ______Poor

Has your child’s vision and/or hearing been checked professionally? If so, by whom and date. ______

______

  1. Is there any suspicion of alcohol or drug use? Explain. ______

______

  1. Is there any history of sexual abuse? ______
  1. Does the child have any problems sleeping?

______None______Difficulty falling asleep____Other ______

______Sleep continuity disturbance______Early morning awakening

  1. Does the child have any allergies? If yes, please explain: ______

______

  1. Does your child take any kind of medication regularly? If yes, explain type and dosage: ______

______

  1. Do you have any concerns regarding your child’s fine motor or gross motor skills? ______

______

  1. Does anyone in the family have a history of: (please check)

______Visual Problems______Seizures or Convulsions______Hearing Problems

______Mental Retardation______Speech Problems______Heart Difficulty

______Emotional Problems______Reading Difficulty

Please Explain: ______

______

Parent Input/Developmental History Form 1