Section 5: Evaluations and Services

Neurobehavior Services

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Background Questionnaire

Confidential: For Report Purposes Only

Thank you for filling out the following questionnaire. Please click "Submit" at the end of each section. (Note: You will not be able to save your progress, so please complete each section fully before submitting.)

Know that this information is very important to the assessment, so please be comprehensive and provide as much detail as possible.

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Section 5: Evaluations and Services

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Child's name *

First

Last

Today's Date *

Form completed by (include relationship to child) *

The following tests or evaluations have been conducted with my child: *

Occupational therapy evaluation Physical therapy evaluation Psychiatric evaluation Psychological evaluation Neuropsychological evaluation School testing Speech / Language testing Vision testing Other (please describe below) None of these

Please provide copies of these records.

For each test or evaluation checked, please indicate the approximate DATE of testing and the RESULTS given (your best recall is fine) *

My child has received the following services (previously or currently)... *

Speech therapy (articulation) Language therapy Occupational therapy Physical therapy Adaptive P.E. Educational therapy Tutoring Educational service (school district) Educational service (private) Social skills training Psychotherapy Assistive technology Classroom accommodations Other (please describe below) Never received any services

For each item you check, please complete all the information requested below. If you run out of space, please use the Notes boxes to provide additional information.

Notes *

Type of service *

Age / Grade of treatment *

Minutes or # of sessions / week *

Type of session *

Name of Provider or Agency (include credentials) *

Type of service *

Age / Grade of treatment *

Minutes or # of sessions / week *

Type of session *

Name of Provider or Agency (include credentials) *

Type of service *

Age / Grade of treatment *

Minutes or # of sessions / week *

Type of session *

Name of Provider or Agency (include credentials) *

If you would like to qualify any responses or add additional notes, please do so here. After you click "submit," you will be redirected to the For Clients page. *

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