Evaluation Forms

Initial Evaluation History Form

for Parents & Caregivers

This form helps us understand your child's unique background, strengths, and needs before the evaluation begins. Your responses are confidential and will only be shared with Kristen Beckley and, with your consent, directly relevant providers. Please take your time — there are no right or wrong answers.

Form Submitted Successfully

Thank you for taking the time to complete this history form. Kristen will review your responses and be in touch soon to discuss next steps for your child's evaluation.

If you have urgent questions, please reach out directly at kristen@kristenbeckley.com.

Child Information

Basic identifying information about the child being evaluated.

Child's Full Name * Please enter the child's full name.

Date of Birth * Please enter the child's date of birth.

Age

Gender

Current Grade * Please enter the child's current grade.

Current School

School District

Parent / Guardian Information

Contact information for the parent or guardian completing this form.

Parent/Guardian 1 Name * Please enter your name.

Relationship to Child * Please enter your relationship to the child.

Phone * Please enter a phone number.

Email Address * Please enter a valid email address.

Street Address

City

State

Zip Code

Parent/Guardian 2 Name (optional)

Relationship to Child

Phone

Email Address

Developmental History

Information about pregnancy, birth, and early development.

Were there any complications during pregnancy?

Yes No

Please describe:

Was the child born full-term?

Yes No

Please describe (e.g., weeks premature, NICU stay):

Were there any complications at birth?

Yes No

Please describe:

Developmental Milestones

Approximate age when each milestone was reached (leave blank if unknown).

First words

First sentences

Walking independently

Toilet training

Were there any early developmental concerns?

Yes No

Please describe:

Strengths & Interests

Help us understand what makes your child unique.

What are the child's greatest strengths?

Hobbies and activities the child enjoys

How would you describe your child's personality?

Three positive qualities you most admire in your child

Additional Information

Is there anything else you would like Kristen to know before the evaluation?

May Kristen contact the child's school as part of the evaluation?

Yes No Yes, with a release form

May Kristen contact the child's other providers (e.g., therapist, pediatrician)?

Yes No Yes, with a release form

Initial Evaluation History Form

Form Submitted Successfully

Child Information

Parent / Guardian Information

Family Information

Reason for Referral

Educational History

Developmental History

Medical History

Behavioral & Emotional History

Strengths & Interests

Additional Information

Initial Evaluation History Form

Form Submitted Successfully

Child Information

Parent / Guardian Information

Family Information

Reason for Referral

Educational History

Developmental History

Medical History

Behavioral & Emotional History

Strengths & Interests

Additional Information

Consent & Signature