Packet for patients five years of age and older - Atlantic Health System

Dear Parent or Guardian:
Welcome to the Child Development Center for initial evaluation. We are a full service child evaluation
team with neurodevelopmental specialists, social workers, psychologists, learning consultants, and
speech and language therapists. To start the process, please complete the two-page Appointment
Intake Form. It is important to answer all of the questions to the best of your ability. The information
provided will aid our team in determining the appropriate appointment(s) for your child at the Child
Development Center. When we receive your two-page Appointment Intake Form, we will call you to
schedule an appointment(s). This is the only form required to schedule your appointment.
Once your appointment is scheduled, please return the completed Childhood History Form at your
earliest convenience, but not later than seven (7) business days prior to your scheduled appointment.
Please fax the completed forms to:
973-290-7164
If you do not have access to a fax machine, please mail your completed documents to:
Child Development Center – Interoffice Box 100
Goryeb Children’s Hospital
100 Madison Avenue
Morristown, NJ 07960
Our office uses RelayHealth for communications and prescription refills. Please provide your e-mail
address below and return this page with your packet so we may enroll you in Relay Health.
Your e-mail address for RelayHealth: ______________________________________________________
Parent’s Name (please print) ________________________________________________________
Child’s Name (please print) ________________________________________________________
Please advise if you would like to schedule an appointment with the next available clinician (please circle)
or provide the name of a specific clinician at CDC ____________________________________________
Please provide the best telephone number(s) and time for CDC staff to call between 8:00 a.m.and 4:00
p.m. to schedule your appointment.
____________________________________________________________________________________
Sincerely,
Kathleen Selvaggi Fadden, MD
Medical Director
Goryeb Children's Hospital
Morristown Medical Center
100 Madison Avenue
Morristown, NJ 07960
Goryeb Children's Center T T: 973-971-5227
Overlook Medical Center
F: 973-290-7164
99 Beauvoir Avenue
Summit, NJ 07901

APPOINTMENT INTAKE FORM
***Please complete entire form (2 pages) before submission***
Today’s Date __________________
Referred by: ___________________________
Patient’s Name ____________________________________
Mother’s Name ___________________________________
Father’s Name ____________________________________
Patient’s DOB _______________
Mother’s DOB _______________
Father’s DOB ________________
Home #________________Wk # (Father/Mother) ______________________Cell #____________________
Home Address___________________________________________________________________________
City______________________State______County_______________________Zip Code_______________
Pediatrician’s Name, address, telephone no.
_______________________________________________________________________________________
PRIMARY INSURANCE: Name & ID No. __________________________________________________
Name of Subscriber: __________________ Insurance Co. Address _________________________________
Relationship of subscriber to insured ______________ Subscriber Date of Birth ____________________
(*Please provide copy of both sides of ALL insurance ID cards)
SECONDARY INSURANCE: Name & ID No. _________________________________________________
Name of Subscriber: __________________ Insurance Co. Address _________________________________
Relationship of subscriber to insured ______________
Subscriber Date of Birth ____________________
Has your child or child’s sibling previously been evaluated here at the Child Development Center?
Yes _____ No _____ If yes, please provide date and explain ____________________________
_____________________________________________________________________________________
Are you concerned about autism?
Yes _____ No _____ If yes, please explain ___________________________________________
_____________________________________________________________________________________
Has your child been formally evaluated/tested by the school Child Study Team? Yes _____
No _____
If yes, Date of evaluation and/or test _____________________
Page 1 of 2

For children 5 years of age and older: Are you concerned about:
(If you answer yes to any questions below, please describe below)
School problems/academic Yes _____ No _____
School problems/behavior Yes _____ No _____
Developmental delay Yes _____ No _____
Attention problems, ADHD Yes _____
No _____
Mood changes, anxiety
depression Yes _____ No _____
Speech and language Yes _____ No _____
__________________________________________________________________________________________
__________________________________________________________________________________________
Has your child been diagnosed with a genetic syndrome or other rare diagnosis? Yes _____ No _____
Does your child have any previous medical history or mental health history? Yes _____ No _____
If yes, please describe ______________________________________________________________________
_________________________________________________________________________________________
Best time to call and best number to reach you between 9:00 a.m. and 3:00 p.m. _________________________
Name of person completing form: _____________________________ Relationship to patient: _____________
Signature: ________________________________________________ Date: ___________________________
For internal use:
Date received: ___________________________________ Reviewed by: ______________________________
Comments: ________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Page 2 of 2

CHILD DEVELOPMENT CENTER
CHILDHOOD HISTORY FORM
For Children Ages 5 Years and Older
Patient Information
Last Name: First Name: DOB:
SS#:
Sex: Male/Female:
Street Address: Race: Religion:
City State: Zip Code:
County:
Home Phone:
Primary Care Physician Name:
PCP Phone Number:
Primary Care Physician Address:
Parent/Guardian Information
Father/ other DOB: SS#
Last Name:
First Name:
Street Address:
City:
State: Zip Code:
Home Phone:
Occupation:
Work Phone:
Employer’s Name and Address:
Mother/other DOB: SS#
Last Name:
First Name:
Street Address:
City:
State: Zip Code:
Home Phone:
Occupation:
Work Phone:
Employer’s Name and Address:
Emergency Contact Name & Phone Number
1

Primary Insurance
Insurance Company Name:
Billing Address
City: State: Zip Code:
Insured’s Name:
Policy Number:
Group Number:
Phone Number:
Secondary Insurance
Insurance Company Name:
Billing Address
City: State: Zip Code:
Insured’s Name:
Policy Number:
Group Number:
Phone Number:
I authorize release of medical information necessary to process insurance claim(s): I authorize
and direct my insurance carrier or it’s intermediaries to issue payment check(s) directly to
Morristown Medical Center, Atlantic Health System and agents and/or intermediaries for services
rendered.
I understand that I am responsible for any amounts not covered by my insurance. Further I
understand that your office cannot accept responsibility for collection my claim or for negotiating
a settlement on a disputed claim. I am responsible for payment of my account within the limits of
our credit policy
Signed: ________________________
Date: ____________________
2

CHECKLIST FOR CHILD DEVELOPMENT CENTER EVALUATION
Your child is being seen by a developmental specialist at the Child Development Center. We
want to know everything about your child to assure that your child will receive a thorough
evaluation. Please fill out this form COMPLETELY. A prescription for Neurodevelopmental
Consultation from primary care doctor is MANDATORY.
Please provide copies for any of the following items that apply at least one week before
your scheduled appointment to preserve your scheduled appointment. You can request
information to be sent to us: Child Development Center, ATTN: Early Childhood, Morristown
Medical Center #100, 100 Madison Avenue, Morristown, NJ 07960. Our fax is (973) 290-7164.
_____ Copy of immunization record and prescription for Neurodevelopmental Consultation
from primary care doctor (MANDATORY)
_____ Birth records, ONLY if there were complications (i.e., prematurity, NICU admission, any
concerns you have regarding the pregnancy or delivery)
_____ Early Intervention Program evaluations and progress notes if applicable
_____ ANY Occupational, Speech/Language and Physical Therapy reports
Please indicate if your child has been to see any of the following specialists. List date and
evaluator and bring reports/results if available.
________ Ophthalmology/Optometry
________ Neurological, Neurodevelopmental
________Gastroenterology
________Cardiac
________Pulmonology
________ Endocrinology
________Audiology/Hearing
________Any relevant MRI, EEG, CT
________Genetics
________Other (scans, lab work, chromosomes, thyroid testing, allergy tests, etc.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________________
3

THIS FORM MUST BE FULLY COMPLETED
CHILD DEVELOPMENT CENTER
EARLY CHILDHOOD HISTORY FORM
For Children ages 5 and over
Today’s Date________
Child's Name (First, Middle, Last)__________________________________________________
Child's Date of Birth _____________________ County of Residence ____________________
Preferred Name or Nick-Name___________________________ Age_________________
If we may contact you by email please provide email address: ___________________________
Cell Phone Contact ____________________ Is this child adopted? Yes/ No
Child is presently living with:
Biological Mother_______ Biological Father_______
Adoptive Mother_______ Adoptive Father_______
Stepmother_______
Stepfather_______
Foster Mother_______ Foster Father_______
Other (specify):______________________________________________
Primary language in home_________
Secondary language in home__________
Name, Address and Phone number of Pediatrician________________________________
___________________________________________________________________________
Who suggested this evaluation? ______________________________________
What specific questions would you like answered by this evaluation? (MUST ANSWER)
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________
Is your child receiving care from a day care center or childcare provider? _________
# of days ________
Name of Provider/Center: _________________________________________________
Please answer if you have any concern in the following areas: Circle you answer
Large muscle concerns
Yes / No _______________________________
Fine motor concerns
Yes / No _______________________________
Speech Language concerns Yes / No _______________________________
Behavior Problems
Yes / No _______________________________
Hyperactivity
Yes / No _______________________________
4

Behavior problems at school
Attention Span
Sensory Integration concerns
Appetite/Nutrition
Social/Eye Contact
General academic concerns
Reading skills
Math skills
Writing skills
Yes / No _______________________________
Yes / No ________________________________
Yes / No ________________________________
Yes / No ________________________________
Yes / No _________________________________
Yes / No _______________________________
Yes / No _______________________________
Yes / No _______________________________
Yes / No _______________________________
List names and addresses of all other professionals except pediatrician involved with the child
(Specialist, Eye doctor, Speech Therapist etc.).
Name Address Phone Conditions being treated
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
PREGNANCY
(IF UNABLE TO COMPLETE FULLY, FILL OUT ALL KNOWN INFORMATION)
Number of pregnancies: ________ Miscarriages/Abortions: _______________
Mother’s age at time of delivery _______ Birth weight _________
Was Child Full Term/ What Gestation ________________________________________
Hospital/Location ________________________________________________________
Complications and Medical Problems of Mother: (Infections; Hypertension; Toxemia; Exposures
to Toxins; Hospitalizations; Bleeding)
_______________________________________________________________________________
_______________________________________________________________________________
Medical Tests: (Amniocentesis, Other)
_______________________________________________________________________________
List all the medications (prescribed or over-the-counter) that were taken while pregnant:
_______________________________________________________________________________
Smoking during pregnancy _______ #cigarettes per day _______________
Alcohol/Other Drug use (specify) ___________frequency _______________
Psychological problems __________________________________________
5

DELIVERY
Type of Labor: Spontaneous or_Induced _________Duration (hrs) __________
Type of Delivery: Normal _______ Breech _________Caesarian______
Reason for Caesarian: fetal distress _____Repeat _____
Complications at Delivery: ________________________________________________
Apgar Scores __________________________________________________________
POST DELIVERY PERIOD
Number of days infant was in the hospital after delivery _______________________
Respiratory Distress (specify # of days for oxygen or ventilation)________________
Infection (specify) ____________________________________
Jaundice______ Treated by lights (phototherapy) _____________________
Was hearing screening normal?______________ Eye problems _______________
Other (e.g. seizures, heart problems, operations, feeding by tube, head bleed)
______________________________________________________________________
INFANCY PERIOD
Has your child exhibited any of the following during any period, to a significant degree,? If so,
describe and note age: _________________________________________
Did not enjoy cuddling ___________________________________________________
Difficult to comfort ______________________________________________________
Excessive restlessness __________________________________________________
Colic __________________________________________________________________
Excessive irritability _____________________________________________________
Frequent headbanging ___________________________________________________
Difficult nursing ________________________________________________________
Constantly into everything ________________________________________________
Other(specify) _________________________________________________________
MEDICAL HISTORY
If your child's medical history includes any of the following, please note the age
when the incident or illness occurred . Please circle ‘None’ if that applies :
Childhood illness NONE _________________________________________________
Hospitalizations NONE _________________________________________________
Operations NONE ____________________________________________________
Head injuries NONE_____________________________________
Convulsions ___________with fever ______________without fever ____________
Allergies: To foods Y / N Medicines Y / N Seasonal Y / N
Explain ________________________________________________________________
6

PRESENT MEDICAL STATUS
Height _________ Weight ___________
Any present illness for which your child is being treated? Y / N _______________________
Does your child take a daily multivitamin? Y / N Flouride? Y / N
Medications or supplements child is taking on ongoing basis Y / N. Please note medication and
dose___________________________________________________________________________
Are immunizations up to date? Yes / No
If No, please explain __________________________________________________
VISION:
Do you have any concerns about your child’s ability to see? Yes / No
Do you have any concerns about weak eye muscles (lazy eye?) Yes / No
Does your child make and maintain eye contact regularly with you? Y / N with others Y / N
Has your child been seen by an Eye Doctor? Yes / No Reason and Results: ________________
_________________________________________________________________________________
HEARING:
Has your child had history of more than three ear infections within a six month period? Y / N
If so when? ________________________________________________________________
Has your child’s hearing been tested by an audiologist since the newborn period? Y/N
If so when/where/results ______________________________________________________
Does your child have myringotomy tubes in place? Y / N ____________________________
Has your child ever seen an ENT doctor? Y / N__________________________________
Do you sometimes feel your child does not hear well? Y / N___________________________
Does your child answer to his name when he/she is called most of the time? Y / N
Has your child had CAP testing (Central Auditory Processing) Y / N ______________________
APPETITE
Use a spoon independently Yes / No
Use a fork independently? Yes / No
Drink from a straw? Yes / No
Eat from all food groups? Yes / NO
Do you find your child to be excessively picky regarding food choices? Yes / No
Does your child put nonfood objects in their mouth? Yes / No
Are you worried about your child’s weight? Yes / No
7

SLEEP
What time is child’s bedtime?______________________________________________________
What time do they tend to wake up?________________________________________________
Where do they sleep? (In own bed, co-bed with parent)? ________________________________
Does your child have a hard time settling down to sleep? Yes/ No_________________________
Do they wake frequently during night? Yes / No ______________________________________
Do they snore regularly? Yes / No __________________________________________________
On average, how many hours of sleep do they get a night? ______________________________
Night terrors? Yes / No_____________________________________________________________
Does your child brush teeth before bed? Yes/No__________________________________
Does your child wet the bed? Yes/No ___________________________________________
DEVELOPMENTAL MILESTONES
Has your child? Yes / No Age of onset Any Concerns
Smiled
Sat without support
Rolled
Crawl
Cruise (walk while holding on)
Walked without assistance
Waving Bye-Bye
Clap on request
Babble sounds like gaga,dada
Use any single word with meaning
Said 2-word combinations
Said 3-word phrases
Began saying sentences
Bladder trained, day
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
8

Bladder trained, night
Bowel trained, day
Bowel trained, night
Rode tricycle
Point out requested body parts (where
is your nose?)
Point to ask you for something (their
cup, a toy etc.)
Point at requested pictures in a book
(Show me the baby?)
Point as if to show you something that
caught their interest, such as to a
plane or squirrel running by
Gesture to communicate, such as
raising 2 hands up to be picked up
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Has your child ever regressed or lost a milestone they previously had ? (For example stopped
saying momma, or no longer pulls self to stand etc.) Yes / No
If so when and what was it? __________________________________________________
Was your child referred to the New Jersey State Early Intervention Program? Yes / No
If so, when and what were results? __________________________________________________
Current Therapy
Does your child currently receive any of the following?
Speech/Language
Physical Therapy
Occupational Therapy
ABA
Basic Skills
Resource Room
Tutoring
Through
School
Private
How many hours/week?
9

SCHOOL HISTORY
Current School Name: ____________________________________________________
School Location: ________________________________________________________
________________________________________________________
Grade: ___________________
Does your child have an IEP (Individual Education Plan)? Y/N ___________________
______________________________________________________________________
Does your child have a 504 Plan? Y/N _______________________________________
______________________________________________________________________
Has your child ever been evaluated by school district/child study team? Y/N
And what were results?
If so, when
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
SCHOOL HISTORY
Rate and comment upon child's school experiences related to learning and behavior:
Early Intervention Program
Comments:
Nursery School/Preschool
Comments:
Kindergarten
Comments:
Elementary School
Comments:
Middle School
Comments:
High School
Comments:
Current Grade
Comments:
10
Good Average Poor

Have any of your child’s past teachers described any of the following as significant classroom
problems for your child? Please check and comment briefly
Often fidgets with hands or feet or squirms in seat
Comments: ____________________________________________________________
Often leaves seat
Comments: ____________________________________________________________
Often runs about or climbs excessively in situations in which it is
inappropriate
Comments: ____________________________________________________________
Difficulty playing quietly
Comments: ____________________________________________________________
Often in “on the go” or often acts as if “driven by a motor”
Comments: ____________________________________________________________
Often talks excessively
Comments: ____________________________________________________________
Often blurts out answers before questions have been completed
Comments: ____________________________________________________________
Often had difficulty awaiting turn
Comments: ____________________________________________________________
Often interrupts or intrudes on others
Comments: ____________________________________________________________
Does not cooperate well in group activities
Comments:_____________________________________________________________
Often fails to pay close attention to details or makes careless mistakes
Comments: ____________________________________________________________
Often has difficulty sustaining attention
Comments: ___________________________________________________________
Often does not seem to listen when spoken to directly
Comments: ____________________________________________________________
Often does not follow through on instructions and fails to finish
Comments: ___________________________________________________________
Often has difficulty organizing
Comments: ____________________________________________________________
Often avoids, dislikes, or reluctantly engages in tasks requiring sustained
mental effort
Comments: ____________________________________________________________
Often loses things necessary for activities
Comments: ____________________________________________________________
Often is distracted by extraneous stimuli
Comments: ____________________________________________________________
Often is forgetful
Comments: ____________________________________________________________
11

HOME BEHAVIOR
All children exhibit, to some degree, the behaviors listed below. Check those that you believe
your child exhibits to an EXCESSIVE or EXAGGERATED degree when compared to other
children his or her own age:
Excessive or
Exaggerated
Fidgets with hands, feet or squirms in seat
Has difficulty remaining seated when required to do so
Runs about or climbs excessively in situations in which it is
inappropriate
Has difficulty playing quietly
“On the go” or acts as if “driven by a motor”
Often talks excessively
Blurts out answers before questions have been completed
Has difficulty awaiting his/her turn
Interrupts or intrudes on others (often no purposeful or planned, but
impulsive)
Easily distracted by extraneous stimulation
Fails to give close attention to details or makes careless mistakes
Has difficulty sustaining attention during tasks or play activities
Does not listen when spoken to directly
Has problems following through with instructions and fails to finish
chores or duties
Has difficulty organizing tasks and activities
Avoids, dislikes, or reluctantly engages in tasks requiring sustained
mental effort
Loses things necessary for tasks or activities at home
Is forgetful in daily activities
Temper tantrums/outbursts
Aggression towards others
Does not seem to learn from experience
Poor memory
A “different” child
Does your child create more problems, either purposeful or non-purposeful, within the home
setting than his or her siblings?
Types of discipline you use with your child
Is there a particular form of discipline that has proven most effective?
Have you participated in a parenting class or obtained other help concerning discipline and
behavior management? ___________________________________________________________
12

COORDINATION
Approximately rate your child’s developmental history on the following skills with a check mark:
Above Average Average Poor Not doing
yet
Walking
Running
Throwing
Catching
Scribbling with a
crayon/writing
Self feeding
Making a block
tower/Legos
Self-dressing
Excessive number
of accidents
compared to other
children (specify)
Do you have any concerns about your child’s motor development? Yes / No_________________
Has your child ever been evaluated by a Physical Therapist? Yes / No______________________
Has your child ever been evaluated by an Occupational Therapist? Yes / No_________________
13

PEER RELATIONSHIPS
Is your child interested in other children? Yes / No___________________________________
Does your child seek friendships with peers? Yes / No________________________________
Is your child sought out by peers for friendship? Yes / No _____________________________
Does your child play with children primarily his or her own age? Yes / No ________________
Younger? _________Older? _____________
Describe briefly any problems your child may have with peers
__________________________________________________________________________________
________________________________________________________________________________
Social / Development
What are your child's favorite toys/ activities?_______________________________
______________________________________________________________________
How much TV does your child watch a day?
______________________________________________________________________
What does your child dislike doing most?
______________________________________________________________________
What do you like most about your child?
______________________________________________________________________
Does your child ever help clean up or put away their toys/do chores? Yes/No
_____________________________________________________________________
FAMILY HISTORY:
COMPLETE ALL KNOWN INFORMATION
Mother_________________________ DOB_________________
Currently: Married___Single___Divorced___Widowed___Separated_____
Years married to current spouse: _________________________________________
School: Highest grade completed_________________________________________
Learning problems_____________________________________________
Attention problems_____________________________________________
Behavior/Social problems_________________________________________
Medical problems______________________________________________
Have any of mother’s blood relatives experienced medical (especially ventricular arrhythmias),
developmental, neurological, psychiatric or emotional difficulties? If so, briefly describe:
___________________________________________________________________________
___________________________________________________________________________
14

Father______________________________________DOB:_______________________
Currently: Married___Single___Divorced___Widowed___Separated____
School: Highest grade completed____________________________________
Learning problems________________________________________
Attention problems_______________________________________________
Behavior/Social problems_______________________________________________
Medical problems________________________________________________
Have any of father’s blood relatives experienced medical (especially ventricular arrhythmias),
developmental, neurological, psychiatric or emotional difficulties? If so, briefly describe:
__________________________________________________________________________________
__________________________________________________________________________
Child’s Siblings:
Name M/F Date of Birth Age Grade / Occupation
1
2
3
4
5
6
Have any of your child’s siblings experienced medical, developmental, neurological or emotional
difficulties? If so, briefly describe:
__________________________________________________________________________________
__________________________________________________________
Has this child or any siblings previously been evaluated here at The Child Development Center
(who and when)? ________________________________________________________________
How long has this child lived in current home? ________List age of child at any previous moves
and how the move was tolerated__________________________
In the case of divorce, please provide custody documents. List visitation
schedule____________________________________________________________
15

ADDITIONAL REMARKS
Please write any additional remarks you may wish to make regarding your child.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________
THIS FORM HAS BEEN COMPLETED BY: Parent/Guardian _____ Other __________
Name_____________________________ Relationship to child ________________
Address _____________________________________________________
Phone/Home ___________ Phone/Work ____________________
Date Completed ________________________
PLEASE ATTACH A PICTURE OF YOUR CHILD, PREFERABLY WITH ONE OR BOTH PARENTS.
This will help us keep an image of your child fresh while we work with your family.
16

New Patient Checklist
□
□
□
□
□
□
Request for consultation or prescription from referring physician
Copy of pediatric vaccination log
Completed Childhood History Form
Photocopy of all insurance cards
Completed registration form
Enclosed CDC Letter
Goryeb Children's Hospital
Morristown Medical Center
100 Madison Avenue
Morristown, NJ 07960
Goryeb Children's Center
Overlook Medical Center
99 Beauvoir Avenue
Summit, NJ 07901
T: 973-971-5227
F: 973-290-7164