Student Intake Form - First Baptist Jackson

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Student Intake Form I. PERSONAL DATA A. Child’s Name

Phone Number: B. Date of Birth

C. Age

D. Gender

E. Child’s Address F. Child Lives With G. Informant for this interview II. HOME AND FAMILY INFORMATION A. Mother – 1. Full Name

2. Age

3. Highest Level of Education Completed

4. Occupation

5. Employer

6. Work Phone

B. Father – 1. Full Name

2. Age

3. Highest Level of Education Completed

4. Occupation

5. Employer

6. Work Phone

D. Others Living in the Home Name 1. 2. 3. 4. 5. 6. E. Native Language Spoken in the Home

Age

Sex

Relationship

F. Describe any changes in the family situation that have affected your child’s behavior.

What were the changes in your child’s behavior?

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III. EDUCATIONAL BACKGROUND A. Did your child attend preschool or daycare before entering kindergarten? If yes, where.

For what length of time?

C. Did your child have any problems with peers, teacher(s), learning activities? If so, describe:

YES

NO

D. Is your child currently passing all subjects? YES NO If no, what subject(s) is he/she having problems with? _________________________________ E. Does your child complete all homework assigned daily? YES NO F. Do you help your child with his/her homework? YES NO If yes, how long do you work together?______________________________________ G. Does your child receive any extra help or special education services? YES NO If yes, explain_____________________________________________________ H. In your opinion, what is your child’s strength and weakness academically? __________________ _______________________________________________________________________________ I.

Has your child been tested previously? YES NO If so, how can we obtain these results?____________________________________________

J.

Has your child received any services in the past? YES NO If yes, give details. ____________________________________________________________

K. Child’s school: L.

M. Child’s grade:

IV. LANGUAGE/SPEECH A. Has your child received L/S services in the past? YES NO If yes, give details. __________________________________________________________ B. Does your child understand what is said to him/her? YES NO C .Does your child follow simple commands? YES NO D. Does your child initiate a conversation? YES NO E .Do you have any concerns about your child’s language/speech? YES NO If yes, what? ________________________________________________________________

V. SOCIAL A. Does your child do what adults tell him to do? YES B. Explain how your child gets along with: a) siblings: b) other children: c) adults: C. Does your child seem to enjoy: a) Playing alone? YES NO b) Playing with other children? YES NO c) Being with adults? YES NO D. Does your child make friends easily? YES NO

NO

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E. Does your child participate in sports activities? (baseball, soccer, band etc.) YES NO If yes, list the activities. _______________________________________________________ F. What are some of your child’s hobbies? ______________________________________________ G. Does your child belong to any clubs or organizations? YES

NO

Child’s Personality & Behavior Traits (check all that apply) Loud Quiet Hard to discipline Friendly Unfriendly Patient Easily Frustrated Even-tempered Unaffectionate Leader Follower Daydreams Likes to be alone Likes to play with others Very active Secure Insecure Attentive Dependent Independent Happy Problems Sleeping No problems sleeping VI. Past Medical History A. What was your child’s birth weight? B. Did your child have any problems at birth or shortly thereafter? Yes_______ No_______ If yes, describe.___________________________________________________________________ C. Has your child been seriously ill, injured, or hospitalized? Yes________ No________ If yes, list any illnesses, injuries, or hospitalizations and child’s age when this occurred.

D. Is your child allergic to any medicines? Yes________ No______________ If yes, give name of medicine(s)._____________________________________________________ E. Does your child have to take medicine regularly? Yes_________ No_________ If yes, give name of medicine(s)._____________________________________________________ F. Is your child being seen by a medical doctor now? Yes________ No_________ If yes, explain____________________________________________________________________ G. Are there any medical problems which you feel should be considered in planning your child’s school Program? If yes, explain___________________________________________________________ _______________________________________________________________________________ H. Do you consider your child’s development to have been slow, normal, or fast?_________________ VII. Family Medical History Are the following diseases found in the immediate family on either side of the family? (Immediate: father, mother, sister, brother, grandmother, grandfather) 1. Sugar Diabetes 2. Sickle Cell Anemia 3. Cancer 4. Mental Retardation 5. Mental Illness 6. Alcohol or Drug Dependency 7. Seizures 8. High Blood Pressure 9. Heart Disease 10. Other_____________________

Yes______ Yes______ Yes______ Yes______ Yes______ Yes______ Yes______ Yes______ Yes______

No______ No______ No______ No______ No______ No______ No______ No______ No______

Who______________________ Who______________________ Who______________________ Who______________________ Who______________________ Who______________________ Who______________________ Who______________________ Who______________________ Who______________________ 3

VIII. Review of Systems Does your child have any of the following problems? If yes, please explain. Please note if your child has received medical treatment for these.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Headaches Ear Infections Hard of Hearing Wear glasses Trouble with eyes More than 3 sore throats a year Heart trouble Dizziness or fainting Asthma Stomach problems Stinging or burning when urinating Kidney Trouble Bed Wetting Hurting or swelling in arms, legs, joints Seizures or convulsions Thyroid problems, dwarfism, other gland problems

Yes

No

If yes, explain

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***Date & results of last vision screening _______________________________________________ ***Date & results of last hearing screening ______________________________________________

IX. ADDITIONAL INFORMATION A. Please provide any additional information that will help us to understand your child better.

A. What is the best day and time to contact you? B. What is the best day and time to arrange a meeting with you?

Form completed by:

Date competed:

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