Kadima Kids Therapy — Parent Questionnaire

About Your Child

Please fill in the details below as accurately as possible. All information is kept strictly confidential.

A1Child's Details

First Name (Legal)*

Last Name*

Nickname

Date of Birth*

Primary Care Pediatrician*

A2Child's Gender*

Male

Female

Please select an option.

A3Primary Language at Home*

Select all that apply.

Yiddish

English

Hebrew

Other

Please select at least one option.

A4School & Teacher*

Is your child currently in school or daycare?

Yes

No

Please select an option.

School & Grade

Current Morah / Teacher

Previous Morah / Teacher

A5Previous Evaluations*

Select all that apply.

None

Speech/Language

Occupational Therapy

Psychological

Developmental Pediatrician

Neurology

Audiology

Genetic Testing

ASD / ADHD

Other

Please select at least one option.

Year, evaluator, findings (if known)

Parent Information

Mother's Name*

Father's Name*

Contact Info (phone / email)*

Address*

A7Referred By*

Pediatrician

School / Teacher

Parent / Friend

Family member

Previous therapist

Rav / Community

Other

Please select an option.

A8Payment Method*

Insurance

Private Pay

Please select an option.

Why You're Here

Tell us about what brought you here and any previous therapeutic support your child has received.

Q1Describe the Concerns*

Please describe your concerns in as much detail as you'd like*

Which categories apply?*

Select all that apply.

Behavior / regulation

Communication / language

Social difficulties

Learning / school

Sensory sensitivities

Sleep

Feeding / eating

Motor skills

Attention / focus

Emotional regulation

Safety concerns

Developmental delays

Please select at least one category.

Q1bSource of Concern*

These are my concerns

Both parents share these concerns

Teacher / school only

Teacher / school and both parents agree

Teacher / school and one parent

Please select an option.

Q2Current or Previous Therapy*

Has your child received any prior or current therapy?

Yes

No

Please select an option.

Check each therapy type that applies, then fill in the details.

Speech / Language

Duration

Therapist name

Frequency

1×/wk

2×/wk

3+×/wk

Discontinued

Not started

Occupational Therapy (OT)

Duration

Therapist name

Frequency

1×/wk

2×/wk

3+×/wk

Discontinued

Not started

DIR / Floortime

Duration

Therapist name

Frequency

1×/wk

2×/wk

3+×/wk

Discontinued

Not started

Social Work

Duration

Therapist name

Frequency

1×/wk

2×/wk

3+×/wk

Discontinued

Not started

Other therapy (describe)

Q3Does the Teacher Share Your Concerns?*

Yes

No

N/A

Please select an option.

Consent to contact teacher for evaluation?

Yes

No

Consent to contact teacher ongoing?

Yes

No

Teacher name & contact info

Early History

Help us understand your child's developmental journey, medical history, and family.

Q4When First Concerned About Development*

From birth (0–6 mo)

First year (6–12 mo)

Toddler (12–24 mo)

Age 2

Age 3

Age 4

Age 5

Starting school

Elementary school

Recently

Please select an option.

What specifically made you start to worry?

If concerns worsened at a particular point, please share when.

Q5Medical History & Post-natal Complications*

Select all that apply.

None / healthy

Premature birth

NICU stay

Birth complications

Feeding difficulties

Ear infections

Reflux

Surgeries

Chronic conditions

Other

Please select at least one option.

Details for any checked items

Q6Pre-birth / Pregnancy History*

Select all that apply.

No complications

High-risk pregnancy

Preterm labor

Significant stress / mental health

Other

Please select at least one option.

Details for any checked items

Developmental Milestones*

For each milestone, choose whether your child reached it within the normal range. If later, please enter the approximate age in months.

Walked

Within normal range (by 18 months)

Later than normal

Talked (first words)

Within normal range (by 15 months)

Later than normal

Toilet trained

Within normal range (by 36 months)

Later than normal

Not yet toilet trained

Any delays or concerns about milestones not captured above

Q7bEarly Milestones — Delay Domains*

Which areas, if any, showed delays? Select all that apply.

No delays

Gross motor

Fine motor

Speech / language

Social smiling / engagement

Toilet training

Feeding / eating

Sleep routines

Please select at least one option.

Specifics about any delay

Q8Family & Siblings*

Two quick questions about your child's place in the family.

How many children in the family (including this child)?*

What number child is this child?*

1 = oldest. If only child, enter 1.

Siblings*

Enter age and gender for each sibling. Name is optional.

Q9Similar Issues in Other Children*

No — not similar

One sibling similar

Multiple siblings similar

Please select an option.

If siblings have similar needs — in therapy? Diagnoses?

Q15Allergies*

Select all that apply.

None

Food

Medication

Environmental

Requires EpiPen

Please select at least one option.

List specific allergens

Q16Hospitalizations*

No hospitalizations

Yes — describe below

Please select an option.

Reason, approximate date, duration

Q17Medications*

Not on medications

Yes — list below

Please select an option.

Medication name(s) and what each is for

Daily Life & Regulation

A picture of your child's daily routines, sleep, screen use, and emotional regulation.

Q14Sleep Routines*

Select all that apply.

Generally fine

Difficulty falling asleep

Night waking

Early waking

Nightmares / terrors

Bedtime resistance

Co-sleeping

Bedwetting

Please select at least one option.

Bedtime routines, sleep environment, anything else helpful

Q18Screen Time*

Approximately how much screen time per day?*

None

< 30 min

30 min – 1 hr

1 – 2 hrs

2 – 4 hrs

4+ hrs

Please select an option.

Any concerns about screen use?

Select all that apply.

Difficulty turning off

Tantrums after

Hyperfocus

Mood worsens after

Notes on screen use

Q19Calming Strategies*

When upset, what calms your child? Select all that apply.

Hugs / physical comfort

Quiet alone time

Music

Movement / rocking

Familiar object

Predictable routine

Talking it through

Distraction

Sensory tools

Hard to calm

Please select at least one option.

Notes about calming

Q10Behavior at Home*

Select all that apply.

No major concerns

Tantrums / meltdowns

Transitions

Aggression toward others

Self-injurious

Following rules

Argues / refuses

Sibling conflict

Anxiety / clinginess

Withdrawn

Please select at least one option.

Anything else about behavior at home

Q11Behavior at School*

Select all that apply.

No major concerns at school

Attention

Completing work

Following directions

Disruptive

Withdrawn

Anxious

Friends

Bullying

Frequent absences

Please select at least one option.

Anything else about behavior at school

Q12Does Your Child Enjoy School?*

Loves it

Generally enjoys

Mixed feelings

Reluctant

Refuses

Please select an option.

What does your child say about school?

Q13Mood Coming Home from School*

Happy / energized

Calm / relaxed

Tired / drained

Irritable / cranky

Withdrawn / quiet

Meltdowns at home

Varies

Please select an option.

Notes about mood after school

Q26Safety Concerns*

Select all that apply.

No safety concerns

Wandering / elopement

Unsafe climbing

Lack of danger awareness

Hurts self when upset

Hurts others when upset

Pica (non-food in mouth)

Other

Please select at least one option.

Notes about safety

Communication & Learning

How your child communicates and processes language and information.

Q20How Does Your Child Express Themselves?*

For each, choose the option that fits best.

Tell a story (something that happened to them)

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Ask a question

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Tell you when they need help

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Tell you when something is bothering them

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Tell you what they want

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Explain how they made / built / drew something

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Describe how something looks

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Explain why they like something

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Q21Following Directions & Processing*

Follows a routine direction (e.g., "Put your shoes on")

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Understands a short story or book read aloud

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

Follows novel or multi-step directions

Easily

Sometimes

With effort

Rarely / not at all

Please select an option.

What helps your child understand and follow directions?

Select all that apply.

Visual cues

One step at a time

Repetition

Demonstrations

Quiet environment

Eye contact / touch

More processing time

Familiar adult

Q22How Often Does Your Child…*

For each, choose how often this typically happens.

Behavior	Often	Sometimes	Rarely	Never
Share an idea or thought with you	•	•	•	•
Initiate ideas for play or activity	•	•	•	•
Try to spend time / play with a parent	•	•	•	•
Share an emotion (good or bad) with you	•	•	•	•

Q23Reactions to Common Triggers*

For each situation, indicate how your child typically reacts.

Trigger	Fine	Mild	Moderate	Hard
Routine changes (schedule, plans)	•	•	•	•
Separating from caregiver	•	•	•	•
Replacing or losing favorite items	•	•	•	•
Crowded areas (stores, simchas, shul)	•	•	•	•
Background noise	•	•	•	•
Visual distractions / busy spaces	•	•	•	•
Not being understood	•	•	•	•
Having to wait	•	•	•	•
Negative emotions in others	•	•	•	•
Non-literal language (jokes, sarcasm)	•	•	•	•
Receiving validation / empathy	•	•	•	•
Meeting new people	•	•	•	•
Going to school	•	•	•	•

Social, Play & Sensory

Tell us about how your child plays, connects with peers, and processes sensory input.

Q24How Your Child Plays*

Select all that apply.

Imaginative play

Building / construction

Cars / dolls / figures

Lines up toys

Repetitive play / scripts

Parallel play

Cooperative play

Prefers solo play

Active play

Art / crafts

Watching only

Please select at least one option.

What are favorite toys, games, or activities?

Q24cWith Peers, Your Child Tends To…*

Lead / direct play

Follow others' lead

Mix

Avoid peers

Frequent conflict

N/A

Please select an option.

Q24bCan Self-Entertain?*

Yes — long stretches

Yes — short bursts

With difficulty

Needs constant engagement

Please select an option.

Q25Common Triggers for Meltdowns*

Select all that apply.

No significant meltdowns

Hunger / thirst

Tiredness

Overstimulation

Unmet expectations

Being told no

Transitions / endings

Frustration

Sensory overload

Unpredictable / unclear

Please select at least one option.

Notes about meltdown patterns

Q27Range of Interests*

Wide range

Average

Narrow

Very narrow / intense

Please select an option.

Describe favorite interests / topics

Q27bType of Interests*

Age-typical

Mixed

Some unusual

Very specific / unusual

Please select an option.

Q28Socialization Patterns*

For each behavior, indicate how often it happens.

Behavior	Often	Sometimes	Rarely	Never
Seeks the company of others	•	•	•	•
Shares fun with others (laughing together)	•	•	•	•
Makes eye contact in conversation	•	•	•	•
Holds back-and-forth conversation	•	•	•	•
Shows interest in what others do	•	•	•	•
Listens / complies with adult requests	•	•	•	•
Cares about how others feel	•	•	•	•
Argues a lot	•	•	•	•
Waits their turn	•	•	•	•
Interrupts others	•	•	•	•
Resists physical touch (hugs, etc.)	•	•	•	•
Tolerates praise / attention	•	•	•	•
Tolerates being told "no"	•	•	•	•
Talks off-topic / monologues	•	•	•	•
Asks questions that have already been answered	•	•	•	•

Q29Sensory Seeking*

Things your child actively seeks out. Select all that apply.

None / no concerns

Spinning / swinging

Jumping / crashing

Tight squeezes

Touching everything

Mouthing items

Bright lights

Loud sounds / making noise

Strong smells / tastes

Constant movement

Please select at least one option.

Notes about sensory seeking

Q30Sensory Avoidance*

Things your child finds overwhelming or actively avoids. Select all that apply.

None / no concerns

Loud noises

Crowded spaces

Bright lights

Light touch

Clothing textures

Food textures

Strong smells

Haircuts / nails

Brushing teeth

Bathing / water

Please select at least one option.

Notes about sensory avoidance

Family & Additional

Almost done! A few questions about family and anything else you'd like us to know.

Q31Recent Family Events / Changes*

Anything in the past year+ that may have affected your child. Select all that apply.

No significant events

New baby

Move / relocation

Change of school

Loss of family member

Illness in family

Parent travel

Family stress

Marriage / divorce

Please select at least one option.

Notes about family events

Q32Family Rav / Spiritual Guide*

Yes — actively consult

Yes — not on this

No

Prefer not to say

Please select an option.

Name & contact (optional)

Q33Anything Else You'd Like Us to Know

Additional notes (optional)

Form Updated

Thank You!

Form Updated

Thank You!

📧 Email me a link

Link sent!

⚙ Kiosk Settings