Early Childhood Guardian Interview Form

Student Name

First NameLast Name

Date of Birth

Date

Gender

MaleFemale

Ethnicity

Language Spoken in the Home

Has your child had any schooling or academic instruction in a language other than English? (For example, learning to read, write, or do math in another language.) If so what age and for how long?

School

Grade

Name of Guardian 1

Guardian 1

Biological ParentFoster ParentAdoptive ParentOther

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Best Number to Reach Guardian 1

Occupation

Email for Guardian 1

Name of Guardian 2

Guardian 2

Occupation

Best Number to Reach Guardian 2

Email for Guardian 2

Student Lives With

Status of Parents

If parents are not together, please explain current living arrangement (e.g. shared physical custody)

Is there a family history of learning, chronic medical conditions, or mental health problems? If yes, please explain.

Are there any concerns with your child's speech/language development? If yes, please explain.

Are there any concerns with your child's gross or fine motor skills? If yes, please explain.

Was pregnancy full-term or premature?

Full-TermPremature (Earlier than 37 weeks)

If premature, how early?

Did the child's mother use any of the following during pregnancy?

Were there any complications during pregnancy or delivery?

Was your child hospitalized in the NICU? If yes, for how long? Please explain.

Please check if your child had difficulty with any of the following skills:

At what age did your child speak their first words?

At what age did your child speak in sentences?

At what age did your child walk without help?

At what age was your child toilet trained?

Check if your child had any of the following:

For those checked, please explain:

Medical Diagnoses (please name diagnosis and when/who diagnosed condition if available)

Is your child currently taking any medication? (Please list medication and reason for medication)

Is your child currently in good health? If no, please explain.

Most recent hearing screen date

Date

Hearing Screen Results

PassFailOther

Most recent vision screen date

Date

Vision Screen Results

PassFailOther

Does your child wear corrective eye glasses?

YesNo

Has your child been exposed to abuse or trauma in their lives? If so, please explain.

Have there been any important changes in your family in recent years? (e.g. moving, death, divorce, new sibling)

Do you have any concerns with your child's eating or sleeping habits? (if so, please explain)

Has your child ever or is your child currently receiving any services outside of school? (speech, counseling, OT, PT, etc.)

Has your child ever been evaluated through special education before? If yes, please provide details.

Please check any of the following that describe your child:

Does your child play well with other children?

Does your child have established friendships with others? If no, please explain.

Do you have any concerns with your child's behavior or social/emotional development? Please explain.

What activities does your child enjoy?

Is your child involved in any activities or programs?

What are your child's strengths?

What concerns do you have for your child?

Please attach any private evaluation reports, health/medical records, or other relevant information to this evaluation.

Person who completed the form (parent/guardian name)

First NameLast Name

Relationship to Child

Date