Parental Early Childhood Assessment

Please complete the Parental Early Childhood Assessment below.

Family Name*

Answer required for "Family Name"

Child's Name*

Answer required for "Child's Name"

Date of Birth*

Answer required for "Date of Birth"

Address*

Answer required for "Address"

Names and ages of siblings.

Answer required for "Names and ages of siblings."

Does your child have the opportunity to interact with other children and/ or adults?*

Answer required for "Does your child have the opportunity to interact with other children and/ or adults?"

Yes

School or program your child is currently attending*

Answer required for "School or program your child is currently attending"

How many hours per week?*

Answer required for "How many hours per week?"

Do you have any concerns regarding your child's health?*

Answer required for "Do you have any concerns regarding your child's health?"

Does your child prefer to play with:*

Answer required for "Does your child prefer to play with:"

Other Children

Alone

Does your child have other playmates:*

Answer required for "Does your child have other playmates:"

The same age

Older

Explain how your child interacts with his/ her playmates.*

Answer required for "Explain how your child interacts with his/ her playmates."

What, if any activities does your child enjoy?*

Answer required for "What, if any activities does your child enjoy?"

Can your child stay on task, complete a task, remain focused? Please describe.*

Answer required for "Can your child stay on task, complete a task, remain focused? Please describe."

Does your child have a set bedtime?*

Answer required for "Does your child have a set bedtime?"

Yes

If yes, what time?

Answer required for "If yes, what time?"

Does your child cooperate willingly?*

Answer required for "Does your child cooperate willingly?"

Yes

Sometimes

Please explain*

Answer required for "Please explain"

Please explain how you set limits for your child.*

Answer required for "Please explain how you set limits for your child."

Please explain how you discipline your child.*

Answer required for "Please explain how you discipline your child."

Is there another caregiver in your home?*

Answer required for "Is there another caregiver in your home?"

Yes

If yes, please explain.

Answer required for "If yes, please explain."

Is there any information you can share with us that will help us to better understand your child?*

Answer required for "Is there any information you can share with us that will help us to better understand your child?"

Name of Parent completing this form*

Answer required for "Name of Parent completing this form"

Date*

Answer required for "Date"

Please fix the highlighted areas below before submitting.

Parental Early Childhood Assessment