Information about · Web viewAre birth mother and birth father related? Yes No If YES, what is the relationship? Sibling Name Birthdate M/F Grade Relationship (full, step, half) Lives

Children's Services

Alvin Buckwold Child Development Program

Kinsmen Children’s Center 1319 Colony Street

Saskatoon, Sk S7N 2Z1Tel: 306.655.1070 Fax: 306.655.2436

Toll Free: 1-877-405-0042INFORMATION ABOUT YOUR CHILD

DATE:

Child’s Legal Name:

Nickname/Preferred Name:

Address Child resides:

City

Postal Code

Phone Number

Birth Date Gender: ☐ Female ☐ Male

Sask. Health # Treaty #

Family Doctor

Who is providing this information and relationship to child:

Who has legal custody?

If this child is in care, please provide name and contact information of the Social Worker responsible for this child

Name Phone #

What are the main concerns about the child?

/tt/file_convert/5b0a130d7f8b9a99488ba0a1/document.docx 1

What questions would you like answered?

PARENT/CAREGIVER INFORMATION

Name

Relationship to Child

Marital Status

Address

City

Postal Code

Home Phone

Business Phone

Email address

Language spoken/understood in the home: Interpreter required: Yes ☐ No ☐

Name of persons child lives with and relationship to child:

C H I L D ’ S P R E N A T A L H I S T O R YList any illnesses during pregnancy:

List any investigations and treatments performed during pregnancy:

How far into the pregnancy were you when you found out you were pregnant? -How many weeks:

Were any of the following used during the pregnancy? Yes ☐ No ☐

YES NO NameCigarettes ☐ ☐ # of packs per day:Prescription medications ☐ ☐Over the counter or non-prescription medications

☐ ☐Non-medical drugs(ie – marijuana, cocaine, herion, etc.)

☐ ☐


Were alcoholic drinks consumed at any time during the pregnancy? Yes ☐ No ☐

If YES to this question, please indicate when alcohol was used during the pregnancy:☐1st trimester ☐2nd trimester ☐ 3rd trimester ☐ throughout most of the pregnancy

Frequency: ☐ once per week ☐ 2 or more times per week ☐ monthly

Estimated Amount each time : (1 drink=1beer, 1 glass of wine, or 1 mixed drink, I shot of hard liquor)☐ 1-2 drinks ☐ 3-5 drinks ☐ 6 or more drinks

List any major stressors during the pregnancy:

C H I L D ’ S B I R T H H I S T O R YName of hospital & city where was the baby born?Birth mother’s name at time of birth:Was the baby premature? Yes ☐ No ☐ -If YES, how many weeks? -What was the baby’s weight at birth? -Were there any concerns about the baby just before or just after birth? Yes ☐ No ☐ (example: jaundice, low heart rate, lack of oxygen, infection, jittery, etc.)If YES- Specify

Did the baby require any time in the NICU? Yes ☐ No ☐- If so, how long? - If yes, where did the baby spend time in the NICU?

Did the baby bottle or breast feed well? Yes ☐ No ☐ If no, please explain:

C H I L D ’ S D E V E L O P M E N T A L H I S T O R Y

Child’s Temperament/Mood: During the first few years of life, was the child:Yes No

Cuddly? ☐ ☐Poor/restless sleeper? ☐ ☐Easily calmed by holding/stroking? ☐ ☐Accident prone? ☐ ☐

Overall mood: “easy” ☐ “unpredictable” ☐ ”difficult” ☐ Other ☐

Motor DevelopmentPlease indicate the motor skills (movements) that the child can perform:

Motor Skill YES

NO Age first Performed

Rolling ☐ ☐

Sitting ☐ ☐

Crawling ☐ ☐


Walking independently (10-15 steps)

☐ ☐

Ride tricycle using pedals ☐ ☐

Use fingers to eat ☐ ☐

Use spoon to eat ☐ ☐

Toilet trained – day ☐ ☐

Toilet trained – night ☐ ☐

Do you have any concerns about the child’s movements (e.g. stiffness, weakness, clumsy, etc.)? Yes ☐ No ☐ If YES, please explain:

Do you have any concerns about the child’s use of his or her hands (e.g. ability to grasp things, reach for toys)?Yes ☐ No ☐ If YES please explain:

FeedingHow does the child eat? By Mouth ☐ Gastrostomy tube (G-tube) ☐ Nasogastric (NG) Tube ☐

Does the child have a special diet? Yes ☐ No ☐ If YES,, please describe:

Is your child a picky eater? Yes ☐ No ☐

Do you have any concerns about the child’s appetite or growth? Yes ☐ No ☐ If yes, please explain:

___________________________________________________________________________________________________________Does the child have problems with

YES NO USED TO

If yes, please describe:

Sucking ☐ ☐ ☐Swallowing ☐ ☐ ☐Spitting up ☐ ☐ ☐Chewing ☐ ☐ ☐Drooling ☐ ☐ ☐Choking ☐ ☐ ☐

SleepDo you have any concerns about the child’s sleep? Yes ☐ No ☐ If YES, please explain:

Speech and Language DevelopmentAs an infant, how much did the child babble? None☐ a little☐ a lot ☐ constantly☐

At what age did the child:/tt/file_convert/5b0a130d7f8b9a99488ba0a1/document.docx 4

Say His/Her first word?Put 2-3 words together?Use sentences?

For children under age 5, how many different words is the child presently saying? 1-10 ☐ 10-50☐ more than 50 ☐If you cannot remember specific ages, were there concerns about the child’s development at any point?Yes ☐ No ☐ If YES, please explain:

Comprehension Skill YES NO Age first noticed and example:Turning to the voice ☐ ☐Understanding simple words (where’s the ball? Where’s mom?)

☐ ☐

Understanding directions (get the cup; put it on the table.)

☐ ☐

Understanding questions (where do you sleep?)

☐ ☐

Is there a family history of speech or language problems? Yes ☐ No ☐ If YES, please explain:

General HealthPast and Present Health Problems: (age and comment if applicable)Ear Infections ☐ Unexplained fevers ☐ Seizures / convulsions ☐Cleft lip/palate ☐ Tics/ twitches ☐ Meningitis ☐Frequent colds ☐ Asthma ☐ ye/vision problems ☐Feeding/ eating difficulties ☐ Failure to thrive ☐ Colic ☐Frequent stomach aches ☐ Bed wetting ☐ Soiling pants ☐

Heart problems ☐ Hearing problems☐ Allergies Yes☐ No ☐ - If YES please specify: - If YES please specify: Hearing tests Yes ☐ No ☐ - Date of hearing test completed/where:

Immunizations up to date Yes ☐ No☐ - If NO, what age was last immunizations given?

Does the child take any prescribed or over the counter medicines, vitamins, herbs or supplements? Yes ☐ No ☐ If YES please list:


Child’s Social / Emotional DevelopmentDo you have any concerns about how the child behaves? Yes ☐ No ☐ If YES, please explain:i.e. temper tantrums for no apparent reason, aggressive, etc.

Do you have any concerns about how the child interacts with other children?Yes ☐ No ☐ If YES, please explain:

Do you have any concerns about how the child interacts with other adults? Yes ☐ No ☐

Does the child show interest in people and things around him/her? Yes ☐ No ☐Does the child have imaginary or pretend play? Yes ☐ No ☐Is the child able to think, talk, and act like other children his or her age? Yes ☐ No ☐ Or, does he or she act like a younger child? Yes ☐ No ☐ If so, in what ways?

Is the child easily upset by any of the following:

Lights- Yes ☐ No ☐ If YES, please explain:

Sounds- Yes ☐ No ☐ If YES, please explain:

Touch - Yes ☐ No ☐ If YES, please explain: Example: bothered by hair cuts, brushing of hair or teeth, touch by other people

Textures- Yes ☐ No☐ If YES, please explain: Example: bothered by tags on clothing, long sleeved shirts

Movement - Yes ☐ No ☐ If YES, explain: Example: spinning, jumping, swinging

What frightens the child?

What calms the child?

E D U C A T I O N H I S T O R YEducation/Intervention

Please list any schools/programs the child is attending or has attended in the past:

Name Years

Level/Grade Any problems (learning/behaviour) Special program?


F A M I L Y I N F O R M A T I O NBirth Parent History Birth Mother Birth Father

NameDate of BirthPresent OccupationHighest level ofEducation completedLearning/attention/behaviour problems?Attended a special class?

Are birth mother and birth father related? Yes ☐ No☐ If YES, what is the relationship?

Sibling Name Birthdate

M/F

Grade

Relationship(full, step, half)

Lives with referred child(Yes/no)

Any behavior/health /learning problems?Please list

Health Problems in the Birth Family

Please check (√) as many as apply and state how the person is related to the child. Indicate if on mother’s side or father’s side.

√ Relationship to child √ Relationship to child

Mother’s side

Father’s side

Mother’s side

Father’s side

Hyperactive ☐ Epilepsy ☐

Genetic syndrome or birth defect

☐ Involuntary tics ☐

Learning problems ☐ Thyroid problem ☐

Cognitive impairment

☐ Speech problems ☐

Developmental delay ☐ Hearing difficulties ☐

Cerebral palsy ☐ Visual problems ☐

Migraine headaches ☐ Behavioral problems ☐/tt/file_convert/5b0a130d7f8b9a99488ba0a1/document.docx 7

as a child

Drinking problem ☐ Emotional/psychiatric disorders (e.g. depression)

☐

Drug abuse ☐ Other ☐

Previous DiagnosesWhat opinions or diagnoses have doctors given you about the child? Please include the name(s) of the doctor(s) and the date of diagnosis.Diagnosis: Given by: Date given:

Are you aware of any assessments planned in the next 6-12 months, other than at Alvin Buckwold Child Development Program? Yes ☐ No ☐ If yes, please explain when, where and by whom:

Additional information that may help us better understand the child?

Consent for Release of Information to: Alvin Buckwold Child Development Program1319 Colony Street, Saskatoon SK S7N 2Z1 Ph 306-655-1070 Fax 306-655-2436

Has the child seen any of the following professionals? If yes, please fill in the contact informationMay we have the consent to exchange information with them and request their reports? If yes, check those you give the consent for, and sign below.CHILD NAME: DATE OF BIRTH:

Professional Consent Contact Information

Speech-Language Pathologist ☐ Yes☐ No

Name: Address:

Phone:Psychologist/Psychiatrist ☐ Yes

☐ NoName: Address:

Phone:Dietitian ☐ Yes


Phone:Social Worker ☐ Yes


Phone:Occupational Therapist ☐ Yes


Phone:Physical Therapist ☐ Yes


Phone:School/Teacher ☐ Yes


Phone:Early Childhood Intervention Program

☐ Yes☐ No

Name: Address:

Phone:Family Doctor ☐ Yes



Phone:

Pediatrician ☐ Yes☐ No

Name: Address:

Phone:Autism Consultant ☐ Yes


Phone:Other Specialists (ie: neurologist; audiologist; geneticist; ears, nose and throat, naturopath, etc)Please identify.

☐ Yes☐ No

Name: Address:

Phone:

Consent to Share Information with the School ie:appointments

☐Yes☐ No

Name: Address:

Phone:

Date:________________________________

Signature of Parent/Caregiver: ______________________________________________

Please Print name of Parent/Caregiver: ________________________________________________


Documents

Information about · Web viewAre birth mother and birth father related? Yes No If YES, what is the relationship? Sibling Name Birthdate M/F Grade Relationship (full, step, half) Lives