Developmental History
Child’s Name: Jennifer Hernandez Nickname Jenni
Date of Birth: 5/1/2006 Date of Evaluation 10/14/2011
Social Security # Age: 5-5
Family address
Parent’s Names Raul
Person Completing this form Father
Who referred you for evaluation?
Why are you seeking help for your child? She is having problems at school; Can’t do
her work, and has no friends ________________
What type of services do you believe are necessary for your child? Not sure
Circumstances and factors regarding this problem: Moved in with father and step-mother after mother lost custody
Do both parents agree about the nature and cause of the problem? Yes No
What do you enjoy most about your child? She mostly listens and helps around the house when asked.
What do you find most difficult about raising your child? I’m worried about her at school;_
teacher says she can’t do any of the work. She argues with her stepmother at home.
What do you see your child doing when he/she grows up? Don’t know.
Who is in charge of discipline in the home? Father
Do all caregivers agree on discipline? Not always. My wife thinks I can be too lenient.
Describe discipline techniques Doesn’t get in trouble a lot; Take away tv.________
What has proven most effective with this child? ____removal of privileges
How does the child respond to discipline? Cries; Goes to her room
Previous Psychological Evaluations
Date of most recent evaluation: N/A Psychologist _____________________
Reason for evaluation __________________________________________________________
Results _____________________________________________________________________
___________________________________________________________________________
Family History
Mother’s Name: Maria Stepmother? No Yes
Mother’s Birth Date 5/18/1990 Highest grade completed 10th
Occupation Currently Incarcerated Employer N/A
Home phone Work phone
Father’s name Raul Stepfather? No Yes
Father’s Birth Date 10/8/86 Highest grade completed 12th
Occupation: Carpenter Employer Self-Employed
Home phone Work phone
Does your child have other parent(s)/stepparent(s)? No Yes
If yes, please provide the following information.
Name Ofelia
Relationship to your child Stepmother; in the home with us Home phone
Name
Relationship to your child Home phone
Parent’s marital status Divorced when Jenni was one year old. I am remarried.
Are there any significant family or marital conflicts? If yes, please describe. Yes. Ofelia & Jenni
fight a lot; I fought with Jenni’s mom a lot before she was put in jail.
Has your child experienced any parental separations, divorces or death? If yes, please explain.
Lived with mother after divorce and father lived in another state and saw her for Christmas only. Taken away from mother at age 4 because of mother’s drug use and neglect.
If parents are separated or divorced, how often does the other parent see this child? No visits right now with mother.
Child is: Natural Adopted Foster
Siblings: Please name all brothers and sisters, their ages, and whether or not they are in the home.
Luis (2 years old; half-brother in the home)_______________________________
Other’s living in the home:
Languages spoken in the home: Spanish/English; Jenni has trouble speaking Spanish and only wants to speak English. She fights with Ofelia, because Ofelia speaks only Spanish at home with me and Luis.
Past or current health problems of mother: See below
Past or current health problems of father: None
Does the family participate in an organized religion? Catholic church every week
Please indicate relatives, if anv, who have been diagnosed with the following:
Developmental problems Neurological Disorder
Seizures Behavioral problems
Drug/Alcohol abuse Mother Learning problems ____
Speech/Language problems Psychiatric problems
Hyperactivity Emotional problems Mother (Depression)
Chronic illness Genetic disorders
Mental Retardation Hearing/Vision problems
Cancer Cystic fibrosis
Diabetes Kidney disease
Hypertension Multiple sclerosis
Migraine headaches Stroke
Physical handicap Alzheimer’s disease
Tuberculosis Huntington’s chorea
Hemophilia Sickle-cell anemia
Parkinson’s disease Tourette’s syndrome
Tay‑Sach’s disease Heart disease
Birth defect Cerebral palsy
Nervousness Head injury
Pregnancy and Birth History
Was pregnancy planned? No Yes Was prenatal care received? No Yes
When did prenatal care begin? After 6 Months How often were prenatal appointments? As scheduled by physician
Age of mother at delivery 16 years old Age of father at delivery 19 years old
Previous miscarriages? No Yes
Indicate if any of the following occurred during the pregnancy:
Difficulty in conception Excessive swelling
Measles/German Measles Flu
Vaginal Bleeding Emotional problems
High Blood Pressure Excessive vomiting
Toxemia Abnormal weight gain Mom gained 15 lbs.
Anemia Hypertension
Other (specify)
Maternal injury (describe)
Hospitalization during pregnancy? (describe) No X‑rays during pregnancy? (when?, why?) No
Medications during pregnancy (type) No
Alcohol or drug use during pregnancy? (frequency, type) Mom smoked marijuana; she also drank sometimes during the pregnancy.
Delivery was: Vaginal Cesarean: Emergency X (breech) Planned
Birth was: Natural Local anesthesia General anesthesia X
Was child born in a hospital? No Yes If no, where?
Length of pregnancy in weeks: 38 Birth-weight: 7 lbs., 1 oz. Length 21 inches
Length of labor in hours 27 hours Apgar scores? Okay
Any complications? Long, difficult labor
Child’s condition at birth: Relatively healthy
Mother’s condition at birth: Fine
Were forceps used for delivery? No Yes Was this a “feet first” delivery? No Yes
Was labor induced? No Yes
Did the baby experience any breathing problems right after birth? No Yes
If yes, describe:
How old was the baby at discharge from the hospital? _One day____________________________
Did the baby have any medical problems after discharge? (describe) __________
Any medical problems in the first 6 months? (describe) Yes, failure to gain adequate weight
__________________________
Did the baby ever need surgery or anesthesia? No Yes
Early Development
Was early development significantly different from the child’s siblings? Not sure
Did the baby have problems with feeding? Yes, had trouble latching on when nursing and mom could not tell if eating enough
Was the baby normally active? Not sure____________________________________________
How did the baby act when held? Sometimes she did not respond, sometimes cried without stopping. She was fearful of many things as a baby, and cried a lot. But it would get better as she got used to people and places. _____
Did the baby gain weight and grow normally? Gained weight slowly, always small for age
Was the child breast or bottle fed? When weaned? Breast fed initially, but because she didn’t grow properly, doctors insisted on bottle feeding
Motor Development
Was the child slow to learn skills like riding a bicycle, skipping, or throwing a ball? Yes, Jenni cannot ride bike yet and had some trouble learning to walk down steps.
What hand does the child prefer to use? Right
Has the child been forced to change writing hand? No
Which hand do the parents/siblings use?
Was physical therapy ever necessary? No
Was occupational therapy ever necessary? No
Please indicate the age at which your child performed the following tasks:
Turn over 7 months Sit independently 10 months
Crawl 12 months Pull self to standing position Don’t remember
Stand alone 15 months Walk alone 18 months
Feed self with spoon Dress self
Did the baby have abnormal gait? (ex., walked on toes?) No
Toilet trained during the day (when) 3.5 years old mostly; sometimes still has accidents
Toilet trained at night (when) Still has accidents
Number of times per week “accidents” occur: 4-5
Any medical reasons for “accidents?” No______________________________________________
Problems encountered during training?
Did the child drool past the age of 2 or have trouble swallowing, when fed?
Language Development
Did the child’s language development differ from siblings or peers? Talked late
Did the baby babble as much as other children? N/A
Did the child use gestures to communicate? N/A
Please indicate the age at which your child performed the following tasks:
Said first word 2 years old Put 2‑3 words together 3 years old
Pointed to what was wanted 1.5 years old Spoke in complete sentences Just started
Recited the alphabet Can’t do Counted to 10 Can’t do consistently
Was speech or language therapy ever necessary (when, why?) Being evaluated now because she
failed language screening
Is the child able to hold a conversation or tell a story? No Yes – sometimes
Is the child’s speech clear and understandable? No Yes – sometimes
Does the child frequently use gibberish or baby words? No Yes
Does the child understand the meaning of “no?” No Yes
Does the child stutter? No Yes
Does the child talk too much? No Yes
Does the child talk too little? No Yes
Does the child’s voice sound like others’? No Yes
Does the child parrot what others say or repeat TV commercials? No Yes
How well does the child follow short directions? Okay
How well does the child follow complex directions? She has trouble understanding sometimes
Medical history
Does the child have difficulty understanding what is said? Yes No: _sometimes______________
Did the parents ever think the child might have a hearing problem? No
Did the child have earaches or infections? (describe) No
Did the child require ear tubes? No
Date of most recent hearing screening & results In school, couple of months ago – Okay
Date of most recent vision screening & results In school, couple of months ago – Okay
Name of child’s physician Dr. Webster
Please list illnesses/injuries/hospitalizations/surgeries:
Date Incident
Age 2 Hospitalized for Failure to Thrive
Age 4 Hospitalized after ingesting mother’s oxycodone
Has the child ever had problems with sleep (describe)
Does the child have a history of any of the following?:
Febrile seizures Epilepsy
Lead poisoning Ingestion of a toxin X see above
Asthma Allergies
Concussion/contusion Loss of consciousness
Headaches Vomiting/nausea
Ear infections Eating difficulties X as infant
Tics/twitching Repetitive movements
Impulsivity Temper tantrums X with stepmom
Nail biting Clumsiness X
Head banging Self injurious behavior
Meningitis Frequent high fevers
Diabetes Over/under weight X
Anti‑social behavior Hydrocephalus
Endocrine disorder Developmental delay X
Psychiatric disorder Encephalitis
What medication is the child currently taking? (Please indicate type and reason).
None
What previous medications were the child prescribed? None_________________________________
Has the child ever had a head injury?(describe) No
Has the child had all vaccinations? Yes
Has the child ever had an EEG or MRI? No If yes, please indicate provider, date, reason and results:
Please describe any behavioral or emotional problems that you believe your child has: She seems sad;
She stays in her room and watches tv a lot; She has no friends_____________
Is there knowledge or suspicion of drug or alcohol use by this child? (describe) No
Is there knowledge or suspicion that this child was ever the victim of physical abuse (describe): Suspicion; Mother’s boyfriend. No evidence. Child never reported.____________
Is there knowledge or suspicion that this child was ever a victim of sexual abuse (describe): No
Does the child manifest any physical problems that were not discussed? No
Educational History
Did the child attend day care? (describe) No
Did the child attend nursery or preschool? (describe) No, was supposed to go to Head Start but mom didn’t follow through
At what age did the child begin elementary school? 5 years old
Please list all schools that the child has attended: St. Thomas Catholic School_______________
Current school and address _____________________________________________________
Grade K Teacher’s name(s) Mrs. Jones
Did the child ever skip or repeat a grade? No; first time in Kindergarten
Have teacher(s) reported problems in any of the following areas:
Reading: No Yes
Attention/Concentration: No Yes
Spelling: No Yes
Hyperactivity: No Yes
Arithmetic: No Yes
Writing: No Yes
Behavior: No Yes
Social Adjustment: No Yes
What subject does the child enjoy most? Doesn’t like school
What subject does the child dislike most?
Has the child ever been evaluated in the school system? (if so, please provide a copy of results) Not Yet
Has the child ever been placed in a special classroom? No
Does the child fight at school or have very few friends? No fights at school; Few friends; Sits alone at lunch and doesn’t play at recess
Has the child received special tutoring outside of school? No
Did the child have trouble with a particular grade? (describe)
If the child has difficulty with a particular subject, does tutoring help?
Does the teacher report problems that are not noted at home? No; only social isolation at school, learning problems
Does the child like school? No
How does the child get along with teachers? She says the work is too hard
Social Behavior and Play
Does the child get along well with other children? No, doesn’t play with other kids_________
Does the child prefer older or younger peers? Prefers to play with younger brother
Does the child get along with adults? Sometimes, mostly just with dad
Does the child make and keep friends? No
Does the child understand social cues (ex., when someone is angry?) ______Not sure______________
Is the child shy? Around familiar individuals? Shy with most people; okay with dad and grandmother who helped take care of her when we were working before she started Kindergarten
Does the child enjoy toys? Watches tv and plays with dolls, stuffed animals
What kind?
Does the child prefer to play with others or alone? Alone or with dad sometimes
Does the child use imagination in play? Sometimes
Does the child initiate play with peers? No
Does the child participate in organized sports? (describe) No
Does the child understand rules? Yes, if asked in simple terms, she understands
Do other parents complain about the child’s behavior? (describe) No
Does the child become overly excited during play? No
How many hours per week does the child enjoy watching TV? 25
What is his/her favorite show? Wonder pets, Disney movies
What activities does the child enjoy? TV_______________________________________________
Does the child have problems with peer pressure? No
Does the child frequently fight with peers? No
Are there any significant conflicts between the child and other family members? Yes – doesn’t get along with her stepmom. Argues with her and says “you’re not my mom”
Has the child’s social skills or relationships recently changed? Not sure – she has been with us for just over a year
Does the child become overly anxious or upset when separated from parents? No
Please describe the child’s personality Not sure
Has your child ever received any psychological counseling? No Yes
When and with whom? Yes, with psychologist for a few sessions right after
custody changed and mom put in jail. ________________
Have any incident in your child’s life caused noticeable changes in his/her behavior? No Yes
If yes, please describe: Feels responsible for mother in jail because of her hospitalization after the oxycodone; Is sad since she can no longer see mom and has been living with us. Doesn’t get along with stepmom – wants to see mom. _______________________________________________________________
Please describe any additional information that would be helpful in understanding your child: