(This form is to be completed if this is your FIRST encounter with the child receiving care)

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* 1. Demographic Info:

GENERAL INSTRUCTIONS: The Early Development and Home Background (EDHB) form is used for the assessment of the early development and past and current home background experiences of the child receiving care. The form consists of two versions: 1)19 P-items, to be completed by the child’s parent or guardian, and 2)8 C-items (herein), to be completed by the clinician. First, the P-items should be completed by the child’s parent or guardian. This can be done independently, prior to meeting with the clinician, or be administered to the parent or guardian by the clinician during the clinical interview with the parent’s or guardian’s response to each question recorded verbatim. Next, the clinician is asked to complete the C-items after a thorough review of the parent’s or guardian’s responses, ask follow-up questions if necessary, and review any additional clinical information that is available.

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* 2. Please review the responses provided by the child’s parent or guardian for items P1-P10 and then, based on all the information available (i.e., parent/guardian’s responses, other information available, and information obtained from the clinical interview), complete questions C1-C4 below.

Early CNS Problems:

  No Yes Unsure
C1. Is there a history suggestive of early neurological damage?

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* 3. Early CNS Problems:

  No Yes Unsure
C2. Does history suggest delayed language development?
C3. Does history suggest possible persistent problems with vision & hearing?
C4. Does history suggest early difficulties in social relationships?

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* 4. Please review the responses provided by the child’s parent or guardian for items P11-P16 and then, based on all the information available (i.e., parent/guardian’s responses, other information available, and information obtained from the clinical interview), complete questions C5a-d below.

Early Disturbances of Home Environment: Early Abuse or Neglect

Question C5; Does history suggest early ...

  No Yes Unsure
a. physical abuse
b. sexual abuse
c. neglect
d. damaging nurturance (e.g. frequent change of caregiver)?

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* 5. Please review the responses provided by the child’s parent or guardian for items P13-P19 and then, based on all the information available (i.e., parent/guardian’s responses, other information available, and information obtained from the clinical interview), complete questions C6-C8 below.

Home Environment:

  Normal Somewhat High High Very High Unsure
C6. Levels of expressed emotion (arguments, expressions of dislike among family members, or criticism of child's behavior, feelings, or individual characteristics) at home are probably ...
C7. Is parent/ caregiver currently depressed?

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* 6. Home Environment Cont'd

  No Yes Unsure
IF ANY ANSWER OTHER THAN "NO" TO QUESTION 7:

C8. If depressed, is parent/ caregiver receiving treatment?

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