Learning Diagnostics and Treatment Questionnaire

Child’s Name: Date of Birth: Child’s SSN: Address(es): Phone(s):

Parent(s) Name(s):

Parent’s Occupations:

Please answer these questions as best as you can. It’s hard to remember everything!

What is your main concern about your child?

Who is your child’s primary doctor? Did he/she refer your child, or did someone else (including yourself) make the referral?

Pregnancy and Birth: Did you have any problems with your pregnancy? Y N Please describe, if yes.

Prematurity? Y N If yes, how early? Any complications? Please describe, if yes:

Birthweight: Length: Type of feeding:

Feeding problems?

Development: How old was your child when s/he: Rolled tummy to back______Back to tummy______Smiled______Sat alone______Babbled______Crawled on belly______Crawled on hands and knees____ Said first real word______Stood alone______Walked______Put words together______Used simple sentences______Was there anything that worried you about your child’s early development?

Nutrition: What types of foods does your child eat?

Is s/he a picky eater?

1 Last modified 4/23/16 Are there any textures that s/he has trouble with?

Has s/he grown well?

Medical Problems: Does your child have any chronic illnesses? If so, please describe.

Is your child on any medications? Please indicate name, dose, and frequency. Any allergies?

Family History: Any history of learning problems, intellectual disability, multiple miscarriages, genetic disorders, mental health problems, need for speech or other therapies in immediate relatives?

Sleep: How much sleep does your child get nightly? Is it hard to get your child to sleep? Any problems with nightmares, awakening frequently, other sleep problems?

Exercise: How much exercise does your child get? What type and how often?

Screen time: How much time a day watching TV? Playing games?

How much time does it take for s/he to do homework (on average):

Behavior: Any problems? Any mental health diagnosis?

Social: How does your child get along with same age peers? With adults?

Please tell me anything else that you think is relevant: (add on back of page or separate page, if needed)

2 Natasha Hays, MD Learning Diagnostics and Treatment Information The Marston Center 677 Woodland Square Loop SE Office # 16 (upstairs) Lacey, WA 98503

Education, Training and Licensure

My education includes a BA at Oberlin College, summa cum laude, with a major in Psychobiology. I have an MD degree from the University of Minnesota and also completed my pediatric residency at the University Minnesota. I am a licensed by the Board of Pediatrics, and I have over 30 years of experience working specifically in developmental and behavioral pediatrics with the Children’s Developmental Services Agency, a branch of the Department of Health and Human Services of the state of North Carolina.

I have specifically trained in testing for numerous developmental difficulties including learning differences/disabilities, which is what I plan to make the focus of this practice. This is a special interest of mine. It is so important to me to show children that they are perfectly intelligent but that there are areas in which they are having trouble, and can compensate. So many children are very discouraged by the time they come to see me.

Nature of Testing

I will do a variety of testing with your child, depending on what the concern is. This will definitely include testing of various brain functions, including auditory and visual memory (and lots of other kinds of memory!), visual spatial skills, sequencing, language, fine and gross motor, and graphomotor (handwriting) skills. I will also include some occupational therapy testing of primitive reflexes and a neurological exam.

With this information, plus a careful interview with you and your child, I will prepare a treatment plan for how your child can best learn and succeed. In some cases, particularly if your child has dyslexia, I am willing to tutor, and I have experience with research-based intervention, as well as having developed my own techniques and methods.

3 Last modified 4/23/16 I take Regence insurance and will shortly be taking Premera, as well. For private pay, my fees are $400.00 for full testing, which includes the test materials and a written treatment plan to be provided for you shortly after the evaluation. I charge $30.00 for an hour of tutoring. If you are unable to make your appointment, I ask for 24 hours notice. I require the full testing fee for a missed appointment that has not been cancelled at least four hours in advance. Exceptions will be made in extreme circumstances.

This type of testing can be covered by insurance in many cases, but not in all. If it does not, I will give you a bill, for which you will be responsible at the time of your appointment. You may try to request reimbursement from your insurance company on your own. I cannot guarantee that it will be paid—that is between you and your insurance provider. It can definitely be added to your deductible.

Confidentiality:

Communication and the results of the evaluation are confidential, unless you sign a release giving me specific instructions to release you information to another person, such as a doctor or teacher. However, there are a few exceptions to this confidentiality. I will disclose information if you or your child inform me that you are going to harm yourself or someone else, if your child informs me s/he has been a victim of a crime, if I am informed of, or have reason to suspect, abuse or neglect of a child, or if I am subpoenaed by court. If I consult another professional about the specific diagnosis or treatment plan, which may occur, I will use no names or identifying information.

Client Acknowledgement

I have read the preceding disclosure information and have been given the opportunity to ask questions clarifying any of its contents. I understand the content of this disclosure.

______Parent or Legal Guardian of Patient Signature Date

______Witness Date