Print Parent History Form — Kristen Beckley, MA, CAGS, NCSP

Section 1

Child Information

Child's Full Name

Date of Birth

Age

Gender

Current Grade

Current School

School District

Section 2

Parent / Guardian Information

Parent / Guardian 1

Full Name

Relationship to Child

Phone Number

Email Address

Mailing Address

City

State

Zip Code

Parent / Guardian 2 (if applicable)

Full Name

Relationship to Child

Phone Number

Email Address

Section 3

Family Information

Child Currently Lives With (check all that apply)

If Other, please specify:

Parents' Marital Status

Is the child adopted?

Yes No

Age at Adoption:

Siblings

	Name	Age	Grade
1
2
3
4

Relevant Family History (e.g., learning disabilities, ADHD, mental health conditions in the family)

Section 4

Reason for Referral

Primary Concerns (describe in your own words what prompted you to seek an evaluation)

Areas of Concern (check all that apply)

Reading / Decoding Reading Comprehension Written Expression Math Calculation Math Reasoning Attention / Focus Hyperactivity / Impulsivity Executive Functioning (planning, organization, time management, working memory, task initiation, flexibility) Speech / Language Social Skills Anxiety Depression / Mood Behavioral Difficulties Sensory Processing Motor Skills Autism Spectrum Intellectual Ability Other: ___________________________

How long have these concerns been present?

Who referred you to this evaluation? (e.g., teacher, pediatrician, self-referred)

What are your goals for this evaluation? (What do you hope to learn or accomplish?)

Section 5

Educational History

Did your child attend preschool or daycare?

Yes No

Were there early concerns about learning or behavior noted before kindergarten?

Yes No

Please describe:

Has your child ever been retained (held back) in a grade?

Yes No

Which grade?

Does your child currently have an Individualized Education Program (IEP)?

Yes No

Does your child currently have a 504 Plan?

Yes No

Has your child ever received special education services?

Yes No

Please describe (type, dates, provider):

Services received or currently receiving (check all that apply)

Speech-language therapy Occupational therapy (OT) Physical therapy (PT) Counseling Tutoring ABA therapy Other

If Other, please specify:

What does your child do best at school?

What are your child's greatest challenges at school?

Extracurricular activities (sports, clubs, arts, etc.)

Section 6

Developmental History

Were there complications during the pregnancy?

Yes No

Please describe:

Was the baby born full-term (at or after 37 weeks)?

Yes No

How many weeks gestation? Any related complications?

Were there any complications during delivery or at birth?

Yes No

Please describe:

Developmental Milestones (approximate age when each occurred)

First Words

First Sentences (2+ words)

Walking Independently

Toilet Training Completed

Were there any early development concerns (speech delays, sensory issues, motor difficulties, etc.)?

Yes No

Please describe:

Section 7

Medical History

Does your child have any significant medical conditions or diagnoses?

Yes No

Please list diagnoses and treating providers:

Current Medications (name, dose, purpose — leave blank if none)

Has your child had any head injuries, concussions, or loss of consciousness?

Yes No

Please describe (when, how, severity, treatment): Current or lingering symptoms since the injury (check all that apply)

Headaches Dizziness / Balance problems Difficulty concentrating Memory problems Slower processing speed Fatigue / Low energy Irritability / Mood changes Sensitivity to light or noise Sleep disturbance Difficulty with word-finding Personality / Behavior changes Academic decline after injury Vision changes Anxiety or depression since injury

Date of Last Physical Exam

Vision problems?

Yes No

Hearing problems?

Yes No

Date of Last Vision / Hearing Screening

Section 8

Behavioral & Emotional History

Does your child display any of the following? (check all that apply)

Difficulty following directions Easily distracted Difficulty staying seated Fidgety or restless Difficulty waiting turn Acts without thinking Difficulty making friends Withdrawn or isolated Excessive worry or fear Frequent crying or sadness Irritability or anger outbursts Aggression toward others Defiance or oppositional behavior Difficulty with transitions Repetitive behaviors or interests Difficulty reading social cues Low self-esteem Sleep difficulties Difficulty with organization Avoids schoolwork or homework

Additional details about concerning behaviors

Significant life events or stressors (e.g., divorce, moves, illness, loss, trauma, changes in school or family)

Has your child received mental health treatment or counseling?

Yes No

Please describe (type, provider, dates, current or past):

Has your child had a previous psychological or educational evaluation?

Yes No

Please describe (type of evaluation, evaluator, date, key findings):

Section 9

Strengths & Interests

What are your child's greatest strengths?

Hobbies and favorite activities

How would you describe your child's personality?

List three positive qualities your child has:

Section 10

Additional Information

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

May Kristen contact your child's school for records and input?

Yes No

May Kristen contact your child's other providers (doctors, therapists, etc.)?

Yes No

Consent & Signature

Printed Name of Person Completing This Form

Relationship to Child

Signature Signature of parent/guardian completing this form

Date

Please return the completed form to Kristen Beckley by mail, scan, or drop-off prior to your first appointment.
Mail: Please contact Kristen for the current mailing address · Email: kristen@kristenbeckley.com · Phone: (978) 255-3044

Initial Evaluation History Form

Child Information

Parent / Guardian Information

Family Information

Reason for Referral

Educational History

Developmental History

Medical History

Behavioral & Emotional History

Strengths & Interests

Additional Information

Authorization & Acknowledgment