Applying for: *

Casa

Elementary

1. How clear is your child's speech? *

(That is, how much of your child's speech would a stranger understand?)

Very Clear

About half

Less than half

2. Is your child toilet trained? *

Yes

No

2a. If yes, please check the appropriate boxes:

daytime urine

daytime stool

nighttime urine

nighttime stool

3. Does your child have any special hom care needs? *

Yes

No

7. Child's birth parents are *

Single

Married

Separated

12. Do you move frequently from one address to another? *

Yes

No

14. Kindly indicate (by putting a checkmark beside the item) if your child has, or has had, concerns with any of the following. Please include your child’s age when you first observed the behavior.

Motor delay – clumsy, falls easily, poor motor skills

Speech and language delay - also speech that is not understandable, does not point, does not follow commands, others.

Hyperactivity – can’t keep still, jumps a lot

Impulsivity

Attention problems – difficulty completing tasks, distractibility, short attention span

Emotional immaturity – temper tantrums, shouts

Poor response to discipline; negativity

Social interaction – ignores family members/children, no eye contact

Aggressive/antisocial behavior – self-injurious behavior, destructiveness, setting fires, fighting, stealing, lying, hitting, biting

Anxiety symptoms

Depression

Play – plays along, lines up toys, does not engage in pretend-play

Adaptive – has to be spoon-fed and dressed

Learning problems

Difficulty falling asleep, wakes in the middle of the night, wakes easily

Eating problems – eating non-food objects, not eating enough, eating too much

Elimination (bowel movement) problems

Somatic (bodily, physical) complaints

Special habits – clapping of hands, shaking of fingers, looking sideways, rocking, head banging, tics, nail biting/thumb sucking

15. How do you deal with these behaviors? *

Ignore

Send child to his/her room

Scold

Spanking

Remove privileges

Lecture or explain

Talk to child

Others

16. Does your child have problems in school?

No

Yes

19. Has your child been assessed and evaluated by a developmental pediatrician?

No

Yes

20. Is your child enrolled in an intervention program (ABA, Occupational or Speech Therapy, Social Thinking, others)?

No

Yes