Developmental History
Please fill in this form to the best of your ability. Required components are marked with an asterisk. If there are other questions that you do not feel comfortable answering you may leave them blank.
Student Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Your email address
*
example@example.com
Language spoken at home:
*
Who does the child live with? (list siblings, parents, others)
*
Check the highest grade completed in school by parent filling in this form.
6
7
8
9
10
11
12
Some college
Associate's degree
Bachelor's degree
Ph.D
Check the highest grade completed in school by other parent.
6
7
8
9
10
11
12
Some college
Associate's degree
Bachelor's degree
Ph.D
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Developmental History
Has the child ever lived with someone or been in foster care for a period of time?
Yes
No
Has either parent or any of the children had a problem (chronic major illness, mental illness, alcoholism, major surgery, unemployment, imprisonment, etc.) which may relate to the child's problems?
Yes
No
Have there been any major family incidents or tragedies which may be related to the child's problems?
Yes
No
Are you the biological parent of this child?
Yes
No
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Developmental History
Areas of Concern
Within areas of concern, check all items that reflect student difficulties when compared with others at the student's grade level. * Note that some items will not be applicable to your student if they are in a lower grade level. Do not check boxes that are not grade level expectations.
Does your student qualify or participate in Response to Intervention (RTI) or Tier 1 support services?
No
Yes, RTI services
Yes, Tier 1 services
They qualified, but are not participating in RTI or Tier 1 support.
Select if this referral is for speech/language.
Speech/anguage concerns only
Speech/language referral with additional concerns
Reading
Does not know letter names
Does not know letter sounds
Does not decode new words phonetically
Does not have the expected sight word vocabulary
Does not read at an appropriate rate
Has difficulty comprehending what is read
Cannot summarize the main idea of passages
Cannot recall details of what is read
Does not display higher level comprehension skills such as making predictions and inferences
Other
Written Expression
Does not write legibly
Has difficulty with motor movements
Does not typically write complete sentences
Does not use appropriate word sequence in writing
Does not use correct grammar
Does not adequately develop ideas in paragraphs
Written expression is not consistent with student's oral expression
Does not typically write passages of appropriate length
Does not express ideas in a clear and organized fashion
Other
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Spelling
Does not spell sight words correctly
Does not spell correctly on written class work
Does not retain spelling words for review tests
Does not spell words phonetically
Other
Math
Must use manipulatives to solve math problems
Does not know basic addition facts
Does not know basic subtraction facts
Does not know basic multiplication facts
Does not know basic division facts
Does not understand basic math operations appropriate to grade level
Has difficulty with concepts of time
Has difficulty with measurement concepts
Has difficulty with money concepts
Has not mastered math readiness skills (such as counting, one to one correspondence)
Other
Content areas (i.e. science, social studies, health)
Does not participate in discussions and express knowledge
Does not understand relevant concepts
Does not understand/follow directions
Does not have the ability to read texts and class materials
Does not have oral language skills adequate for participation in class discussions
Does not have the writing skills necessary to complete class assignments
Does not retain content information
Other
Communication
Does not attend/listen in a group setting
Does not appear to understand questions, discussions, and/or stories
Does not use correct sentence structure and grammar in oral communication
Does not express ideas in a clear and organized fashion
Cannot hold a conversation with a peer
Cannot hold a conversation with an adult
Does not use appropriate social communication (eye contact, etc.)
Has articulation difficulties (does not use correct speech sounds)
Speech is generally unintelligible
Stutters
Other
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8/2/26, 12:10 PM
Behavior
Does not complete assigned in-class work
Does not complete homework
Does not follow classroom/school rules
Interactions with other students are inappropriate
Interactions with teachers/adults are inappropriate
Is verbally or physically aggressive
Does not respond appropriately to consequences
Does not attend to tasks
Is impulsive
Behavior interferes with the learning of the class
Does not participate in classroom discussions
Does not react to praise appropriately
Does not react to failure appropriately
Does not respond appropriately to authority
Has difficulty changing to another task
Asks for directions/help inappropriately
Does not control frustration
Does not make eye contact
Does not demonstrate appropriate mood/affect
Talks out at inappropriate times or other than when called on
Does not stay in seat or assigned work area
Lacks confidence
Does not have adequate self-help skills (e.g. toileting, dressing)
Exhibits repetitive or stereotyped patterns of behavior
Other
Motor skills
Prints first name
Holds pencil correctly/demonstrates control of scissors
Writes legibly (age-appropriate skills)
Has ability to copy from board and books
Appears coordinated, movements are fluid
Other
5/10
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Developmental History
What is your main concern for your child/the reason you are seeking a special education referral? *
*
Do other members of the family have similar problems? *
*
What do you feel are your student's strengths? *
*
Describe the child's current social interactions (e.g. do they have friends, how do they play/interact with peers, siblings and in groups, etc.) *
*
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8/2/26, 12:10 PM
Developmental History
When did your child meet the following developmental milestones?
Rows
Early
On time
Late
Sat up
Crawled
Walked
Fed him/herself
Used a spoon
Said first word
Was toilet-trained
Said two or more words
Spoke using simple sentences
Socialization
Check the box of any of the characteristics listed below which applied to your child during the infant and early years of development.
Shy or timid
Bed wetting
Expressed lots of affection
Breath holding
Daredevil behaviors
More interested in things than people
Difficult to make up his/her mind
Less active than most children
Very active, restless
Verbalized and talked a lot
Didn't talk as much as peers
Played well with others
Highly interested and curious as a child
Less attentive than most children
Seemed immature when compared with peers
Unusual fears
Rocking
Head bumping
Cried more than others
Withdrawn/wanted to be left alone
Hit, hurt or was aggressive towards other children
Didn't seem as aware of dangers as most children
Other
7/10
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Developmental Medical
Hearing and Vision
Date and result of last vision screening
*
Have you ever had reason to think your child might have poor eyesight?
Does your child wear glasses?
*
Yes
No
Has your child ever been seen by an eye specialist? If yes, give results.
Date and result of last hearing screening
*
Does your child wear hearing aids?
*
Yes
No
Has your child ever been seen by an hearing specialist? If yes, give results.
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Developmental History
Physical and Medical
Describe any physical or medical problems that your child experiences (ex: allergies, asthma, ADD, ADHD, Ear problems, etc.)
Is your child currently on medication or treatment, and if yes, explain.
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