What do you want us to call your child? (nickname) *
Your answer
Please list the names and ages of siblings: *
Your answer
Has your child had experiences in playing with other children? *
Your answer
Has your child had any previous group experience? *
Your answer
Does your child know anyone currently enrolled at St. Theresa's?
Your answer
How does your child usually react to new situations? *
Your answer
How would you describe your child's personality? *
Your answer
Does your child have any special fears? *
Your answer
Is your child right handed or left handed? *
Does your child have a tensional outlet? (thumb sucking, head banging, nail biting, hair pulling) *
Your answer
How does your child show his/her feelings? *
Your answer
At what age did your child begin talking? *
Your answer
Does your child have any speech problems? *
Your answer
Can your child dress herself/himselt? *
Your answer
Is there anything else we should know about your child?
Your answer
Do you have particular expectations of our program regarding your child's development?
Your answer
Eating
What is your child's general attitude towards eating? *
Your answer
Does your child have any food allergies? *
Your answer
Can your child feed himself/herself? *
Your answer
Sleeping Habits
What time does your child go to bed at night? *
Time
:
AM
PM
Does your child have his/her/ own room? *
Your answer
Does your child have any special habits at bedtime (such as sleeping with a blanket or stuffed animal, etc.)? *
Your answer
Does your child take naps? *
If so, how long are his/her naps? *
Your answer
Does your child have a bottle at night or naptime? *
Your answer
Does your child wear diapers to bed at naptime or at night? *
Your answer
Can your child be relied upon to indicate his/her bathroom wishes? *
Your answer
Does your child need to go more frequently than usual for his/her age? *
What word is used for urination? What word do you use for bowel movements? *
Your answer
If trained, does he/she have accidents? *
Your answer
Does your child wet the bed at night? How frequently? *
Your answer
We are pleased to be able to share in this important developmental period in your child's life. What means of sharing information is most convenient for your? Do you prefer phone calls, individual conferences, evening or daytime meetings, emails? *
Your answer
Please add any additional information that you believe was not included.