The Floortime Center Development and Behavior Questionnaire
**Only fill this out if you are already receiving services at The Floortime Center and have been directed to by one of the staff**
Email address *
Today's Date *
MM
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Child's Name *
Your answer
Name of Person Filling out Form *
Your answer
Section 1: General Greenspan Floortime Info
How much Greenspan Floortime are you (parent1) and parent2 doing per day *
A Lot (3 or more 30 minute sessions a day
Medium (two 30 minute sessions a day)
A little (one 30 minute session a day)
None or less then one 30 minute session per day
Parent1
Parent2
How much screen time is your child getting per day on average? *
Is your child able to play/interact with you, or another caregiver, and maintain the interaction for 20-30 back and forth circles? (Think of unstructured or non-repetitive activities) *
How many play dates per week is your child having? (sports practices/teams do not count) *
If you answered less than 2 per week, then please explain why that is the case.
Your answer
Section 2: Behavioral Info (Optional). If your child is experiencing new or increasingly challenging behaviors then please fill out the 4 questions below.
What behavior are you observing (i.e., Defiance, aggression, limit testing, sleep disruptions, etc.)
Your answer
How long has this been going on?
Your answer
Has it gotten...
What are the trigger(s) that typically preceed the behavior? (i.e. Transitions, demands, stimulating social settings, limits, etc.)
Your answer
Section 3: Below are 5 areas we look at when trying to figure out why a child is making slow progress or if we are seeing a behavioral change. Please list any and all possible changes in life, even if you think they are insignificant or unrelated.
Have there been any changes with the family or at home? (i.e., work status, visitors, basic routines at home, sibling(s), marital patterns, etc.) *
Your answer
Have there been any changes theraputically? (i.e., new therapies, new therapists, stopping/pausing a therapy, etc.) *
Your answer
Have there been any environmental changes? (i.e., allergic or toxic reactions, exposure to paints, pesticides, new carpeting, construction materials, moving to a new living space, etc) *
Your answer
Have there been physical changes? (i.e., diet, health/illness issues, medications, etc.) *
Your answer
Have there been any changes at school? (i.e. schedule, teachers, other students, the program, etc.) *
Your answer
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