Please complete the following information prior to your child’s first appointment with Dr. Collin Dean, PsyD.
Other Members of the Household (for example, siblings, step-siblings, foster children):
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Other Regularly Involved Adults (for example, grandparents, non-custodial parents/step-parents):
Note the month in which your child achieved the following activities:
(Normal development: Sit 6-8 mos; Crawl 9 mos; Walk 12-18 mos; Feed 10-12 mos; Speak 10 mos; Toilet 24-36 mos)
Which of the following have recently been or currently are problems with your child?
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