LYNN SCHILLER, Ph.D

License #4506

Tel: 908-410-8596  |  47 Maple Street, Suite L-9, Summit, NJ 07901  |  LynnSchiller@gmail.com 

DEVELOPMENTAL HISTORY & BACKGROUND

FAMILY MEMBERS

Are Mom and Dad still married?

SIBLINGS

OTHERS LIVING IN THE HOUSEHOLD

FAMILY MEDICAL HISTORY

PREGNANCY

Is your child adopted?
Please check if any of the following occurred
Please check and indicate the frequency of use during pregnancy if applicable
Please check and indicate the frequency of use during pregnancy if applicable

PREGNANCY QUESTIONS

Was your child full-term?

CHILD'S INFANCY

LANGUAGE DEVELOPMENT

Does your child have difficulty organizing his/her ideas?
Can he/she retell a story in logical order?

MEDICAL HISTORY

Please note if your child has had any of the following condition and at what age

SCHOOL HISTORY

Has he/she ever been evaluated by a Child Study Team?

SOCIAL DEVELOPMENT

TREATMENT HISTORY

Has your child ever been referred to counseling or other psychological services before?

CURRENT CONCERNS

Is your child aware of your concerns?

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