CDC Application Form

Entrance Date

Withdrawal Date

Parent Questionnaire

Child's Name

Child's Address (Street, City/State, ZIP)

Phone Number

Date of Birth

Sex (M/F)

Social Security Number

Medicaid Number

Child Lives With:

Relation

Referred By:

Phone Number

Home & Family Information

Mother's Name (Last, First)

Age

Highest Level of Education Completed:

Occupation

Employer

Work Number

Father's Name (Last, First)

Age

Highest Level of Education Completed:

Occupation

Employer

Work Number

Others Living in Home

Name

Age

Sex

Relationship

Any Problems or Exceptionalities

Does anyone in the immediate family have on of the following?

Medical Problems

Physical Problems

Emotional Problems

Hearing Problems

Is their anything in your culture that we should know about? Example, is there anything that your child cannot eat due to religious beliefs, any activities that you do not want your children involved in, etc.?

Referral Information

What is your child's main problem? Select any that may apply:

Speech

Physical

Hearing

Sight

Behavior/Emotional

What have you been told by doctors, teachers, and/or others about your child's problem?

How long have you been aware of this problem?

Agencies from which your child receives or has received services:

Agency Name

Contact Person

Phone Number

The following special accommodation (5) may be required to most effectively meet my child's needs while at the center:

Developmental History

Motor Skills

Sat Unsupported

Crawled

Walked Alone

Fed Self

Bladder Trained

Bowel Trained

Language

Doe you feel that your child hears well?

How does your child communicate?

Crying

Gestures

Words

Sentences

Estimate present vocabulary size.

0-25 Words

25-100 Words

Over 100 Words

Eating

Is your child on a special diet?

Yes

What Type?

Does your child have food allergies?

Yes

Please describe:

What does your child use to drink?

Bottle

Sippy Cup

Regular Cup

Other

Please describe:

Sleeping

Does your child nap?

Yes

How long?

Does your child sleep with a certain blanket or toy?

Are there specific bedtime routines at home?

Social/Emotional & Behavior

Is your child comfortable in group situations?

Yes

Is there anything that we need to know about your child's play with other children, by themselves, any concerns?

What are some activities your child enjoys?

What are some activities that your child avoids?

How would you describe your child's temperament and personality?

What soothes your child?

What frightens your child?

Does your child have any favorite songs, movies, or games that comfort them?

Is there anything regarding your family, extended family, or child that you would like for us to know?

Health, Medical, & Community

Pediatrician

Phone Number

List any operations, illness, and/or injuries your child has had:

Operation, Illness, Injuries

Age

List any allergies that your child has:

List any medications that your child is presently taking:

Medication

Dosage

Reason for Giving

Parent Questionnaire

Home & Family Information

Referral Information

Developmental History

Motor Skills

Language

Eating

Sleeping

Social/Emotional & Behavior

Health, Medical, & Community

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