Early Childhood Evaluation Intake Packet


Thank you for interest in an early childhood evaluation at Center for Family Development (CFD).

Please complete the form below. This form must be completed before we are able to provide services for your child. Once you have submitted this intake packet and accompanying documents, we will call you to schedule a diagnostic intake interview and will inform you of next steps.

If you have any issues when completing the form, please call (541) 342-8437.

Thank you for your time completing the following form. We look forward to seeing you!

 

Information about Early Childhood Evaluation services and frequently asked questions can be found at the end of this form.

 

 

**Please complete this form for the person who is receiving services**

Legal Name: Last Name at Birth: Preferred Name: Date of Birth:  

Name of person completing form (if other than individual):  

Name and relationship of referral source:

If other, please explain:  

Physical Address: City, State, Zip: Mailing Address (if different): City, State, Zip:  Okay to send mail?

 

Contact Phone Numbers: 

Primary phone number: Phone Type:

Number belongs to: Okay to leave a message?
If someone else answers, is it okay to identify as CFD and leave a detailed message with them?
 

Alternate phone number: Phone Type:

Number belongs to: Okay to leave a message?
If someone else answers, is it okay to identify as CFD and leave a detailed message with them?

Email address:  

How would like to receive documents from the agency?

Please choose only one; you may contact CFD should your preference change.

 

Gender as Specified on Insurance:

Gender Self-Identification, if different:
If other, please describe:

Pronouns:

If other, please describe:  

Race:

 Ethnicity:

 

Living Status:

Tribal Member:

Tribe Name:  

Preferred Language:

Is a translator needed?

 

Household Income:

Estimated gross household yearly income: $

Number of people supported by household income (include self):

Number of child dependents (Ages 0-17 supported by household income):  

Principle Income Source: 

Emergency Contact Information:

Name: Relationship: Address:

Phone number:  

Are any family members currently receiving services at CFD?

 

Do you have a close friend or family member who works at CFD?

 

Medical Information:

Primary Care Physician's Name (PCP):

Phone: Fax:

When was the last time you saw your PCP?  

 

Dentist's Name: Phone: Fax:  

 

Psychiatric/Psychiatric Nurse Practitioner Name:

Phone: Fax:  

 

List all medications (from the doctor, over the counter, vitamins and supplements) that your child is taking now:

Has child had vision tested in the past year?

If yes, results:
 

Has child had hearing tested in the past year?

If yes, results:
 

Immunizations up to date?

 

Allergies (Please list):

Pregnancy and Birth Information:

Birth parent's age at baby's birth:  

How many times has birth parent been pregnant:  

Which pregnancy is this child:  

Child is in foster care or adopted and perinatal history is limited:

 

During pregnancy did the birth parent have:

Diabetes:

High blood pressure:

Water broke more than 24 hours before delivery:

Birth parent used prescription medications:

Birth parent smoked cigarettes:

Birth parent drank alcohol:

Birth parent used recreational drugs:

Birth parent experienced significant stress, emotional trauma, and/or physical trauma:

Other serious illness/pregnancy complications:

 

Delivery:

Induced labor:

 

Forceps used or vacuum extraction:

 

Delivery by c-section:

 

Twins or multiple births:

 

Baby was early:

 

Baby was late:

 

Birthweight: Length:  

Other complications:

 

After delivery baby had:

Serious breathing difficulty:

 

Infections:

 

Jaundice:

 

IV or tube feedings:

 

Seizures or convulsions:

 

Required a stay in Neonatal Intensive Care Unit (NICU):

 

Baby discharged home:  

Other concerns:

 

Other Health or Systems Concerns:

Vision concerns:

 

Hearing concerns:

 

Frequent ear infections:

 

Feeding difficulties (choking, swallowing, gagging):

 

Birthmarks:

 

Heart murmur or congenital heart defect:

 

Poor appetite:

 

Picky eater:

 

Frequent constipation:

 

Bed wetting:

 

Daytime urinary accidents:

 

Seizures or convulsions:

 

Muscle tics or twitches:

 

Serious head injury or loss of consciousness:

 

Delays in speech sounds or words:

 

Is your child hard to understand when they talk?

 

Are there other languages spoken at home?

 

Other concerns:

 

Developmental Milestones:

Rolled over:

 

Sit up without support:

 

Crawling:

 

Walking independently:

 

Started to babble sounds ("dada", "baba"):

 

Used first words:

 

Used 2-3 word phrases:

 

Used sentences:

 

Pointing to what they want or see:

 

Playing social games like peek-a-boo:

 

Toilet trained during daytime:

 

Family Medical History:

List any family members with history of developmental delays, difficulties in school, genetic conditions, mental health diagnoses, or any other information you would like us to know:

Social History:

In the last year, have you utilized other social service agencies (e.g. DHS Child Welfare, Self Sufficiency, Social Security)?

If yes, where: Name of caseworker, if applicable:  

In the last year, have you accessed other behavioral health or provider agencies like Center for Family Development?

If yes, where:  

Some people experience things that make life more difficult. Please check the things listed below that you are concerned about as the child's parent:

Would you like us to connect you with community resources that could assist you with any of the items checked above?

 

Adverse childhood experiences in the home or community can impact a child's behaviors and well-being. Have any of these happened to your child? Please indicate if you would prefer to speak to these experiences in person:

 

A parent with mental health difficulties:

 

Exposure to domestic or physical violence:

 

Conflicts between caregivers about caregiving:

 

Death of a family member:

 

Parent has been incarcerated or involved with justice system:

 

Foster parent placement:

 

Custody disagreement:

 

Parent substance/alcohol use:

 

Sexual abuse to child:

 

Physical abuse to child:

 

Neglect to child:

 

Parent separation/divorce:

 

Education and/or Childcare:

Does your child go to daycare, school, or preschool?

 

Name of program:  

Grade:  

Does your child have an Individual Family Service Plan (IFSP) or an Individualized Education Plan (IEP)?

 

Does your child receive early intervention services through EC CARES or another agency?

 

Name of Early Intervention Program:  

Please select the services your child has received currently or in the past, and where they received the services:

Speech-Language Therapy:

 

Occupational Therapy:

 

Physical Therapy:

 

Behavioral Supports:

 

Mental Health Counseling:

 

Parent Training/Classes:

 

Other:

Current Concerns and/or Reason for Referral:

What do you hope to get services from CFD?

What are you most concerned about for your child?

When did these concerns begin?  

What has been tried to help the concerns (medications, interventions, treatment, etc.)?

Where do you feel you could use the most help?

What are your child's strengths?

What are your child's favorite activities?

Additional Information:

Is there anything else that you would like us to know about your child?

 

 

The following is about YOUTH only. Parent or Guardian: Please complete the information below.

Children and parents often experience emotional and/or behavioral difficulties during and following family separation, divorce, or other family conflict. Our goal is to help children and families find solutions so they can carry on with their lives in a productive manner. Please let your therapist know if your family is dealing with the impact of any conflict, separation, divorce, or a change in custody or visitation. CFD will not attempt to gather information to help one parent “win” custody or visitation. Please note:

  • CFD does not provide custody evaluations or make recommendations for custody or visitation.
  • CFD staff and therapists will not voluntarily testify in court related to recommendations for custody or visitation.
  • Biological parents who retain parental rights have legal access to participate in therapy and request records, regardless of who has custody, until the child turns 18, and have a legal right to clinical records of minors age 13 or younger.
  • CFD therapists will work to include all parental figures in therapy unless involvement creates a potential or real safety risk for the child and/or family members.

Name of adult(s) legally authorized (legal guardian) to consent for services: 

Biological parent(s): 

Stepparent(s): 

Adoptive/Foster parent(s):

Significant others involved in the child's life:

With whom does the youth live?

Is there a legal parenting plan or custody agreement in place?

 

If yes, please note: CFD requires a copy of the legal documentation of parenting or custody agreements in order to provide services. The legal guardian must be present to consent for services.

Is custody being contested?

 

If yes, please describe: 

Has the court terminated anyone's parental rights?

If yes, full name(s):  

 

Early Childhood Evaluation Services

 

CFD provides psychological evaluations for children ages 0-5 with a referral from a qualified licensed medical professional or from the Department of Human Services. You and your child will be supported by a licensed psychologist to address the following types of referrals and concerns:

 

  • Evaluations addressing cognitive, adaptive, and social-emotional functioning, including autism evaluations.
  • Behavioral and social-emotional evaluations for children being served by the Department of Human Services for the purpose of treatment and intervention planning for placement and reunification decisions.
  • Recommendations for treatment planning and resources for children diagnosed with developmental concerns, autism, and social-emotional diagnoses (trauma and stressor-related disorders, PTSD, etc.).

 

CFD does not provide evaluations for the following referrals or concerns:

  • Early childhood ADHD-specific evaluations
  • Custody or legal evaluations
  • Second opinion evaluations

 

Frequently Asked Questions

 

What is the purpose of an early childhood psychological evaluation? The purpose of the evaluation is to address your family’s concerns, questions and priorities. We will use standardized tests and informal assessments in a play-based way to provide information about your child’s level of functioning, social-emotional needs, and aspects of everyday life. After the evaluation, we will develop recommendations and provide resources based on the assessment findings.

 

Do I have to separate from my child? In most cases, you will not be asked to separate from you child. You are the expert on your child, and therefore are an important part of this evaluation. We will ask you questions about how your child is at home and other pertinent information. We ask that you stay close to your child, as needed, throughout the evaluation. At times, we may observe the child-caregiver relationship, and this will require a brief separation. If this is needed, we will take the time to explain this process to you and why it is helpful.

 

How do I get an evaluation for my child? To determine if your child needs an evaluation, a referral from your child’s primary care provider or pediatrician will be needed before we can schedule an appointment. If the child is in the custody of Department of Human Services and social-emotional or behavioral evaluation is warranted by a caseworker, this type of referral is also accepted. Once we receive your referral, we will call you regarding next steps and scheduling.

 

What areas does an early childhood evaluation measure or address? An evaluation will typically address the following areas, however, this may change based on your child’s needs and the referral concern:

  • Cognitive and developmental functioning
  • Social and emotional interactions/engagement
  • Sensory information and response to sights, sound, touch, and movement
  • Review of medical and developmental history
  • Adaptive functioning (toileting, eating, self-care, etc.)

 

Where is the evaluation completed? The early childhood evaluations will occur in the CFD Central Building located at 1234 High Street, Eugene, OR 97401.

 

Who will be part of this evaluation? A licensed pediatric psychologist, primary caregivers/family members and the child will be part of the evaluation. Due to CFD being a training facility for university students, there may be students observing or participating in the evaluation. This will only occur with your permission, however.

 

What does an evaluation day look like? The evaluation process begins with a clinical intake appointment that is typically 90 minutes in length. The intake appointment allows us gather your child’s comprehensive developmental history and briefly observe your child. You will be asked questions about your child’s behaviors at home and/or school, and asked to complete one or more questionnaires. This is your chance to share your child’s strengths and areas of concern with someone who understands and specializes in early child development and mental health. Based on your child’s unique history and the information you provide, we will develop an assessment plan. 

 

In most cases, the evaluation will start in the morning, and last upwards of 3 hours. Some evaluations take less time, but it should not take more than 3 hours. During this time, your child’s cognitive development and social-emotional functioning will be assessed. Your child will be observed as they interact with the psychologist and with you. During the evaluation, breaks can be taken as needed, as well as toileting and snack breaks.

 

To ensure your child has the chance to do their best, in some cases we may decide to evaluate your child over the course of several days. If this is the case, we will discuss this with you and your family. Once the evaluation is over, you can return back home. Your family feedback meeting to go over results will be scheduled for the following week as a virtual or in-person appointment; whichever you prefer. 

 

How many people can I bring to the evaluation? As the rooms can be small and we will want ample space for your child to play and roam, we typically advise that children be accompanied by at most 2 adults.  However, if it seems warranted, exceptions can be made.

Do you provide evaluations in languages other than English? Yes, CFD will provide a translator to complete the evaluation in your child’s primary language.

 

What should I bring to the evaluation?

  • Food or snacks
  • Diapers, wipes, extra clothes
  • Your child’s preferred toys or items of comfort
  • Copies of previous evaluations, medical records, early intervention records, etc.

How do I prepare for the evaluation beforehand? Make sure your child is well-rested and fed prior to the evaluation, if this is possible. Have your child dressed in comfortable clothes that are easy to play in.

 

Will I get a copy of the evaluation results? The psychologist will write a report documenting the results of the evaluation. The report will be ready in approximately one month. You will receive a copy of the report in the mail, or you can pick up the report in-person. The final report is also sent to your child’s primary care provider if needed. If you would like others to receive a copy of the report, such as early intervention providers or the school system, then you will sign a release of information form at the time of the evaluation.

 

What happens after the evaluation? After the evaluation you will be scheduled for a family feedback meeting for the following week. At this meeting, results, diagnoses, and treatment recommendations will be shared to ensure your child’s well-being. This can be virtual or in-person. A month after your family feedback appointment, a follow-up appointment will be scheduled to check in on you and your child, and to answer any questions or concerns you may have. If you find yourself having difficulty accessing the resources or recommendations that were provided to you, you can discuss it with the psychologist at this time.                                                                             

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