Family Report

Your input is essential to targeting developmental skills that are important for your child. Section 1 asks general questions designed to help program staff get to know your child and family. Section 2 asks specific questions about daily routines and activities. You may complete this form independently or with assistance from program staff. Thank you for sharing this information, and please let us know if you have any questions.

Date(s) completed: September 13, 2021
Child’s name: Marcus Greene
Child’s date of birth: May 24, 2017
Family’s name and address: Veronica Greene
3873 Red Run Road, Baltimore, MD 21211
Person completing form: Veronica Greene
Relationship to child: Mother
Phone/text number: 443-123-6789
E-mail address: [email protected]
Preferred method(s) of contact: Email
Language(s) spoken at home: English

FAMILY REPORT

Section 1: Child and Family Information

Tell us about your child. Child’s name:
How would you describe your child in a few words? Full of energy, happy, loving, friendly

What are some of your child’s strengths?
He loves to make friends and play with his classmates.

Do you have any concerns about your child’s development or behavior? If yes, please explain.
Marcus doesn't seem interested in reading books with me. And sometimes he has a A LOT of energy.

Tell us about your family.

Whom do you include as part of your family (parents, siblings, relatives, close friends, caregivers)?
His father, sister, aunt and uncle, and grandma and grandpa

What would you like program staff to know about your family’s traditions and values?
We have a very strong sense of community within our family

What other information you would like us to know about your family (strengths, concerns, needs)?
Marcus' father and I work very long hours, so we rely on our relatives frequently for child care.

Tell us about services you and your child currently receive and how our program can best support your family.
What is your preferred location and time to meet?
At our home, later in the evenings

Are there other people you would like to include in meetings about your child? If yes, please list.
Grandma and grandpa should attend our meetings

What services do you or your child receive? What other programs does your child attend?
None

What medical providers or specialists does your child see (doctor, physical therapist, occupational therapist, speech therapist)?
He sees his pediatrician

Would an interpreter or cultural guide help us to better serve your child and family? No

Section 2: Activities

Participating with Family

1. What family activities usually involve your child? Check all that apply:
   • Meals
   • Chores
   • TV/movie watching
   • Games
   • Vacations
   • Shopping
2. Would you like your child to participate in other family activities? If so, please explain.
   When Marcus is able to, it would be great for him to participate in chores around the house.
3. What makes your child’s participation in family activities enjoyable?
   He is so joyful and loves to be around his family.
4. Are there things that make your child’s participation in family activities difficult? If yes, please explain.
   Sometimes Marcus can be stubborn and resistant to family plans or sudden changes.
5. Would you like help improving your child’s participation in family activities? If yes, please explain.
   We'd like to see him be more agreeable to all family activities, not just the ones that he chooses.

Eating

1. Where, when, and with whom does your child usually eat?
   He usually eats at home with our family.
2. What kinds of foods does your child eat?
   He likes Cheerios and French toast for breakfast. For lunch and dinner, he prefers chicken nuggets or hot dogs.
3. What makes nursing/meals enjoyable?
   Marcus enjoys mealtime and is always happy to eat his favorite foods.
4. Are there things that make nursing/meals difficult? If yes, please explain.
   No, mealtime usually goes very well.
5. Would you like support with your child’s eating skills or routines? If yes, please explain.
   No, support is not needed here.

Sleeping

1. What is your child’s daytime sleep routine?
   Marcus will usually take a nap after lunchtime.
2. What is your child’s bedtime routine?
   We'll help Marcus get into his pajamas, brush his teeth, and then get into bed.
3. How long does your child usually sleep during the day? At night?
   His afternoon nap is usually 30-45 minutes. At night, Marcus usually sleeps for 10 hours.
4. What makes naps/bedtime enjoyable?
   The time that we can spend close together, reading and talking and snuggling before bedtime.
5. Are there things that make naps/bedtime difficult? If yes, please explain.
   When Marcus has a lot of energy, it can be difficult to get him ready for and in bed.
6. Would you like support with your child’s sleeping routines? If yes, please explain.
   Marcus needs some more support with getting dressed/undressed, bathing and brushing his teeth.

Dressing and Toileting

1. What is your child’s routine for dressing (dressing, changing clothes, undressing)?
   Marcus has some trouble with larger clothing like sweatshirts and jackets, but he is able to take off smaller items more easily.
2. What is your child’s routine for toileting?
   Marcus is fully independent when he goes to the bathroom.
3. What makes dressing and diapering/using the toilet enjoyable?
   Sometimes Marcus is able to fasten buttons and zippers, which we like to celebrate.
4. Are there things that make dressing and diapering/using the toilet difficult? If yes, please explain.
   Marcus has trouble getting dressed on his own, so it can take more time to help him get dressed and ready.
5. Would you like support with your child’s dressing or toileting skills or routines? If yes, please explain.
   We'd like to work on him becoming more independent when he gets dressed/ undressed.

Bathing

1. What is your child’s routine for bathing?
   We start a bath, fill up the tub, get a few floating toys, and bubbles if Marcus wants them.
2. What makes bath time enjoyable?
   He loves playing with his toys in the water and splashing around in the bath.
3. Are there things that make bath time difficult? If yes, please explain.
   Marcus has trouble bathing himself, so we need to help him throughout bath time.
4. Would you like support with your child’s bathing skills or routines? If yes, please explain.
   Yes, we'd like to help Marcus become more independent during bath time.

Traveling

1. How do you and your child get to appointments, meetings, or activities (walk, ride the bus, take a cab, drive a car)?
   We typically drive in our car to appointments, meetings, and other activities.
2. What makes traveling with your child enjoyable?
   Marcus likes to point out interesting sights and vehicles as we drive from place to place.
3. Are there things that make traveling with your child difficult? If yes, please explain.
   No, Marcus is a very good traveler.
4. Would you like suggestions to help your child travel more easily? If yes, please explain.
   No, Marcus is OK with traveling.

Playing

1. What are your child’s favorite play activities?
   Marcus likes to play and build with blocks and play with stuffed animals.
2. When and where does your child play with others (adults, siblings, relatives, friends)?
   Throughout the day Marcus will play at home and in his childcare program.
3. What makes playing enjoyable?
   You can tell how much he enjoys playing with his friends and it puts the biggest smile on his face.
4. Are there things that make playing difficult? If yes, please explain.
   The hardest part is getting him to stop playing when time is up.
5. Would you like support with your child’s play skills? If yes, please explain.
   No, Marcus is great here.

Communicating

1. How well does your child understand what you say?
   Marcus understands what others say to him very well.
2. How does your child communicate (using words, making sounds, pointing, nodding, crying, moving toward something)?
   Marcus talks in complete sentences.
3. Do others understand what your child says?
   Yes other adults and children can understand him.
4. What makes talking to your child enjoyable?
   He's very expressive, and hearing him improve his speech and vocabulary is always exciting.
5. Are there things that make talking to your child difficult? If yes, please explain.
   He occasionally has trouble following longer, multi-step instructions.
6. Would you like support with your child’s communication skills? If yes, please explain.
   We'd like Marcus to work on asking questions to get information he wants. And he could use some support on his conversational rules, too.

Making Changes

1. Does your child have difficulty changing from one activity to another? If yes, please explain.
   Sometimes a quick unexpected transition can cause him to become upset. But it's not very common.
2. Would you like help supporting your child changing between activities? If yes, please explain.
   No we're working on it at home. But if it becomes more common we may need additional support.

Participating in the Community

1. What community activities usually involve your child? Check all that apply:
   • Movies
   • Park visits
   • Sports
   • Worship services
   • Other:
2. Would you like your child to participate in other community activities? If yes, please explain.
   marcus does well in almost all community activities. movies can be tough because he has a hard time sitting quietly for longer periods of time.
3. What makes your child's participation in community activities enjoyable?
   He loves to be involved in things, especially if there are other children there for him to play with.
4. Are there things that make your child's participation in community activities difficult? If yes, please explain.
   As most kids do, marcus has some trouble sitting still and quietly for a longer period of time.
5. Would you like support to help improve your child's participation in community activities? If yes, please explain.
   If we could work on skills that help him attend things like the movies, that would be excellent.

Is there anything else about your child you would like to share or discuss?
Nothing else that I can think of.