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Parental Early Childhood Assessment
Parental Early Childhood Assessment
Please complete the Parental Early Childhood Assessment below.
Family Name
*
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Child's Name
*
Answer Required
Date of Birth
*
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Address
*
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Names and ages of siblings.
Answer Required
Does your child have the opportunity to interact with other children and/ or adults?
*
Answer Required
Yes
No
School or program your child is currently attending
*
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How many hours per week?
*
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Do you have any concerns regarding your child's health?
*
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Does your child prefer to play with:
*
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Other Children
Alone
Does your child have other playmates:
*
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The same age
Older
Explain how your child interacts with his/ her playmates.
*
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What, if any activities does your child enjoy?
*
Answer Required
Can your child stay on task, complete a task, remain focused? Please describe.
*
Answer Required
Does your child have a set bedtime?
*
Answer Required
Yes
No
If yes, what time?
Answer Required
Does your child cooperate willingly?
*
Answer Required
Yes
Sometimes
Please explain
*
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Please explain how you set limits for your child.
*
Answer Required
Please explain how you discipline your child.
*
Answer Required
Is there another caregiver in your home?
*
Answer Required
Yes
No
If yes, please explain.
Answer Required
Is there any information you can share with us that will help us to better understand your child?
*
Answer Required
Name of Parent completing this form
*
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Date
*
Answer Required
Confirmation Email
Confirmation Email
*
Email Required
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