Inspire Diagnostic Pre-Eval Form
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Name *
Date of Birth *
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DD
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Gender *
Address *
City *
Referred By *
Pediatrician Name *
Can evaluation report be sent to your pediatrician? *
Primary Parent/Guardian Name
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Primary Parent/Guardian Phone Number
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Primary Parent/Guardian Email *
Child's Place of Birth *
Birth Weight *
Prenatal problems? *
Additional Parent/Guardian’s Name and Relationship *
Siblings (name(s), age)
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Parent/Guardian's Employment  *
Mental illness presence in family? If so, please describe
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Substance abuse disorder presence in family? If so, please describe
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Who all lives at home? *
Primary Languages spoken at home *
Additional Languages spoken *
Walking Age *
Talking Age *
First Words (other than mama or dada) *
Age of first phrases and what were they? (e.g. More please. I’m thirsty.)
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How does your child currently and primarily communicate? Select all that apply. 

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Required
List examples of how your child communicates *
Age when you first noticed something was not quite right? (In months)
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What was concerning at that time?
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Was there a moment when you thought, “Everything was ok before this moment,” and what was that moment and behavior?
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Age when first potty trained
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Was there ever a moment when your child had the ability to speak or use a skill, such as being potty trained or able to dress themselves, and then lost the ability to perform those skills?

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How well do you think your child understands what you say, without the use of gestures?
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How do you know when your child needs your help or wants your attention? Do they use gestures or sounds/words first?
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Is your child able to point to show interest?
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Does your child make eye contact while pointing?
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Can your child nod to indicate, “yes”?
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Can your child shake their head to indicate, “no”?
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Can your child wave hello/goodbye?
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Can your child shush you to mean, “be quiet”?
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Can your child blow a kiss?
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Can your child clap to mean, “good job”?
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Can your child make direct eye contact with you and others while talking?
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Does your child smile in greeting?
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Does your child offer to share things such as food or toys with you?
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What are some of your child’s favorite activities, toys, or objects?
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Does your child have any unusual preoccupations or interests (vacuums, toilets, street signs, etc.)?
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Does your child have any compulsions or rituals?
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Is your child sensitive to noise?
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Does your child have an attachment to any object that they like to carry around with them?
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Does your child have any repetitive motions involving their fingers, hands, or whole body, such as flicking their fingers, wringing their hands, bouncing, spinning, or rocking?
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Have you noticed anything unusual about the way your child walks, such as walking on their toes, bouncing, etc.?
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Has your child been aggressive towards caregivers or family members? 
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Has your child been aggressive towards people outside of the family? 
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Does your child self-harm?
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Does your child ever breathe deeply and repeatedly, as if they are hyperventilating?
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Does your child ever have fainting spells or a fit, seizure, or convulsion? 
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Does your child make/keep friends easily?
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Is your child currently enrolled in any services or enrolled in services in the past?
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Is your child in school? What grade? *
Special Education involvement? *
Do they have an IEP? *
Presence of any learning disorders or other developmental issues?
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Does your child need accommodations for school that are not currently being offered?
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History of or current presence of abuse or neglect?
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Do you feel safe at home? *
Behavior problems at school or home? *
Eating disorder or body image issues?
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Any self-harming behaviors?
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Medications (psychiatric or other)
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Any current medical diagnosis? 

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Previous surgeries?

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Previous hospitalizations?
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Previous major illnesses?
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What are your biggest concerns for your child at this moment?
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Is there any other information that you feel should be considered before making a diagnosis?

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