Candlelight Foundation

Important Notice

This form is to be completed by the child's parent or legal guardian. All information is strictly confidential and will only be released in accordance with HIPAA guidelines and as mandated by law. Please fill out all required fields (marked with *) before proceeding.

Child & Family

Development

Health & Behavior

Consent

Child Information

Basic information about your child

Child's Full Name * Please enter the child's name

Birthday *

Gender *

Male Female

Address *

Age *

City *

State *

Zip Code *

Guardian's Phone *

School Information

Current educational placement

School Name *

Date Enrolled *

Grade *

Days and Times of Attendance

Teacher's Name

Teacher Contact Information

Did the teacher report any problems?

Family Information

Parent/Guardian details

Mother/Guardian

Full Name *

Address (if different from child)

Occupation *

Phone *

Email *

State/City/Zip

Father/Guardian

Full Name *

Address (if different from child)

Occupation *

Phone *

State/City/Zip

Marital Status of Parents

Married Divorced Single Separated

Parent with Custody *

Was the Child Adopted?

Yes No

Referred By

Program of Interest (select all that apply)

Centre-based ABA Home-based ABA

Development Milestones

Please indicate the age at which your child achieved these milestones

Rolled over consistently

Sat up unsupported

Stood

Crawled

Walked unassisted

Said first word intelligibly

Said 2-3 word phrases

Used sentences regularly

Toilet trained (day)

Dry through night (6+ months)

Dressed self

Fed self

Colored

Social Skills Assessment

Please indicate if your child is experiencing any of the following

Plays independently

Yes No

Plays with toys appropriately

Yes No

Attempts to involve others in play

Yes No

Engages in interactive play with peers

Yes No

Engages in pretend play

Yes No

Spontaneous vocalization/language

Yes No

Imitates sounds/words/phrases

Yes No

Communicates wants/needs

Yes No

Follows simple directions

Yes No

Labels items/events/actions

Yes No

Answers WH questions

Yes No

Engages in verbal exchanges

Yes No

Imitates simple gestures (fine motor)

Yes No

Imitates gestures with objects

Yes No

Imitates gross motor skills

Yes No

Problems making/keeping friends

Yes No

Problems sleeping

Yes No

Problems controlling temper

Yes No

Problems with authority

Yes No

Anxiety

Yes No

Unmotivated

Yes No

Concentration difficulties

Yes No

Self-Care Skills

How well does your child complete each activity?

Dressing