Intake Interview

Law Of Attraction For Kids

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I need to ask you some questions that will give me information to help plan this assessment.

What is your child's full name?____Your full name?___

What is the address and phone number of the program?_____

Who are the child's primary caregivers?_____

What are the ages and occupations of primary caregivers?___

What was the final school grade completed by primary caregivers?__

If divorced or separated, what are the living arrangements regarding the child?

In what country/state/city was child born?____

In what country/state were caregivers born?____

If English is not dominant, who speaks which language to whom?.

If parents are not U.S. born, what were the circumstances of immigration?

What is child's dominant language?_

Who is primary medical care provider? Please tell me what brings you here._

Who referred you?

Have there been any previous evaluations? Please give me the approximate dates, and if you have not already provided copies of reports, please sign a release so that these can be obtained.___________

What specific questions do you have for the assessment? What information would you like to find out?___________

I need to ask you for some additional background information to help answer your questions. How would you describe your child?________

What do you enjoy the most about your child?

What do you find the most challenging about raising your child?

Tell me about your child's early development. What do you remember about the pregnancy and delivery?___________

[Note: If child was adopted, be careful regarding confidentiality in front of child. Note circumstances of adoption and anything known about early history. Does child know about adoption?]

Complications regarding pregnancy? Medications while pregnant? Bleeding?

Any substances (smoking, alcohol, drugs)?

Emotional climate during pregnancy?

Gestation period?

Length/difficulty regarding labor?

Birth weight?

Delivery complications?


Condition of baby?

Do you remember the Apgar scores?

How was the baby when first brought home? Any concerns?

What is child's current health status?

Any illnesses?



Lead ingestion?





High fevers?

Ear infections?

I will ask you some questions about the child's early development.

At what age did the child first:



Say first words? (What were they?) Say full sentence? (What was it?) Toilet train?

What is the child able to do independently now? Bathing? Dressing? Playing? Out in neighborhood?

Who is involved in taking care of the child when not in a program or when caregivers are away?____________

What are the child's experiences regarding separation other than day care or preschool?

Status of child's hearing and vision? When checked?

Is the child taking any medication? What? How much? For how long? With what results?

Has anyone in the family needed any special help in school or have history of special education? ___________

Is there any family history of mental illness? Please explain.

Tell me about a typical day for you and your child; start when you get up.

Now tell me about a typical week; start with Monday.

Tell me about your neighborhood.What is it like?

Tell me about your home. What is it like?

Where and with whom does your child play?

Describe your child's play.

What opportunities does your child have to play with other children?

Does your child participate in any organized recreation?

Let's review the sequence of program experiences for your child from the very earliest to the present. Also, tell me how well your child did in each. What did the teachers tell you?

How do you handle discipline? Who does what regarding discipline? How often is it necessary to discipline your child, and for what?_______

What are the primary sources of stress in your family?

What are the primary sources of support in your family?

Are there any experiences that you think might have had an important impact on your child?

You have already thought a lot about the reasons you brought your child here. What have you told yourself; what do you think is going on that accounts for your concerns? Also, what have others, perhaps in your family or from your friends, told you?

Is there anything else you think I should know that would be important for understanding you and your child?___________

Is there anyone who should get a copy of my report?

To summarize:

You are mainly concerned about:

You are asking for information about:

What I'll be doing will be:

You will be involved in the assessment, but ...

I won't be able to answer your questions about how your child did until we are finished.Then I will meet with you and we will review your questions and look at what the assessment offers to address these. We will work together to make the best possible plan for your child.

Lidz, Carol S. Early Childhood Assessment. Copyright 2003, John Wiley & Sons.

as nonintrusively as possible, using abbreviations and shortened sentences for efficiency. It is advisable to apologize for the need to write but state that it is a necessary aid to memory and accuracy. Avoid burying your nose in the form, and maintain a conversational, clinically sensitive, and open style of communicating. The interviewees should never feel that the primary agenda is to complete the form; the form is a means to facilitate the interaction, and what they have to say is of utmost importance. Nevertheless, there is an agenda to secure this important information, and the assessor needs to exert subtle control over the interaction to reach this goal.

In addition to determining this information, the interview also provides an opportunity for the caregivers to get a feeling for the assessor and for the assessor to get a feeling for the personalities and interaction styles of the caregivers. If the child is present, this serves to introduce the assessor to the child as well, and it is useful for the child to hear the assessor interact with the caregivers without being pressured to respond. Of course, if the child is present, it is necessary to use good judgment regarding the content of the conversation, and the assessor may need to suggest an opportunity for a private conversation for sensitive material.

Sattler (2002, p. 20) also listed a number of types of statements that are helpful for further probing without leading the interviewees in any particular direction. These include the following:

• Is there anything else?

• What happened before?

• What happened after?

• How did you feel? (Please do not overuse that one!)

• What were you thinking?

These of course need to be used appropriately. Sattler (p. 23) further offered a number of reflective statements that would contribute to a sense of active listening that is so important in interview situations:

Such statements help convey a feeling of being heard and understood and avoid implications of evaluation or judgment by the assessor.

Lentz and Wehmann (1995) also provided a number of helpful suggestions to facilitate active listening (p. 642):

• Decide to listen closely.

• Be alert, lean forward, maintain eye contact, use appropriate facial expressions.

• Keep in mind that the goal is to understand, not to evaluate.

• Be reactive, with nods and vocalizations.

• Allow the speaker to finish speaking.

• Show empathy with actions and words, try to see the situation from their point of view.

• Ask clarifying questions.

• Notice nonverbal behavior.

• Avoid thinking about yourself.

• Avoid hasty conclusions.

• Correct environmental distractions.

Assessors need to learn about themselves as well, particularly in terms of how they come across to others and of the types of reactions that they tend to elicit in others. However, it is not advisable to bring this self-consciousness into the interview unless the assessor can quickly process how he or she may have provoked or elicited a particular response from the interviewee. As a general rule, I try to process what I am hearing in terms of how it will help me understand the situation, make decisions about how to proceed with the assessment, and communicate how I can (or cannot) be helpful. Assessors need to clarify the caregiver's expectations and be explicit about how these will be addressed in ensuing sessions.

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