Developmental Questionnaire

"*" indicates required fields

1. Is your child not performing to grade level at school?*

Yes

N/A

2. Do you feel there are gaps in your child’s learning?*

Yes

N/A

3. Does your child seem to be either overly sensitive or seek out sensory experiences more so than most people (auditory, tactile, visual, movement, taste, or smell)?*

Yes

N/A

4. Does your child have difficulty with new motor skills or balance?*

Yes

N/A

5. Does your child have delays in motor development, sitting up, walking, jumping, etc.?*

Yes

N/A

6. Does your child become overwhelmed easily in community settings?*

Yes

N/A

7. Have you noticed a change in your child's mood, behavior, sleeping habits, or eating pattern lately?*

Yes

N/A

8. Do you feel that your child worries more than other children their age?*

Yes

N/A

9. Do you have concerns about your child's behavior at home or school?*

Yes

N/A

10. Did/does your child suffer from colic, reflux or constipation or as an infant?*

Yes

N/A

11. Did/does your child frequently arch their neck/back, feel stiff, or bang their head?*

Yes

N/A

12. Does your child have night terrors or difficulty sleeping?*

Yes

N/A

13. Does your child have social or emotional challenges?*

Yes

N/A

14. Does your child not have a regular, well-formed bowel movement daily?*

Yes

N/A

15. Does your child exhibit any picky eating tendencies? (due to taste preferences or sensory/texture preferences)*

Yes

N/A

16. Does your child exhibit excess drooling, breathe through their mouth, or have frequent ear infections?*

Yes

N/A

17. Do people outside of your family have trouble understanding your child’s speech?*

Yes

N/A

18. Does your child seem to have difficulty following directions?*

Yes

N/A

Please describe any concerns or YES’s from above or additional concerns you may have.

PARENTS/CAREGIVERS:

19. Were there any major stresses/challenges during pregnancy?*

Yes

N/A

20. Did you have any birth interventions or complications? (C-section, Breech, Induction, Pain medications, Epidural, Episiotomy, Vacuum extraction, Forceps, Other)*

Yes

N/A

21. Do you feel like hormone fluctuations (cycle pain, energy dips, mood changes, brain fog, etc.) interfere with your ability to be as effective as you want to be?*

Yes

N/A

22. Do you need help with finding a flexible childcare situation?*

Yes

N/A

23. Do you struggle with balance and selfcare?*

Yes

N/A

24. Do you wish you had a place/avenue to socialize or bond with your child?*

Yes

N/A

25. Do you have a physician that you feel actually listens to your concerns (about you or your child)?*

Yes

N/A

Please describe any concerns or YES’s from above or additional concerns you may have.

Name*

First Last

Email*

Phone*

Answering YES to any of the above questions could indicate a need within your family. Conscious Community Collectives offers a free, no strings attached and confidential consultation to help understand these needs and a possible path forward and link to a local service or resource that can help with your specific areas of need. Submitting this questionnaire will allow us to contact you to help you in this journey with no obligation on your part.

Please note CCC does not guarantee any outcomes based on our recommendations. The consultation conversation is simply to help you identify a potential path forward and link you with local and reputable services providers that can help.

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