Child's full name

DOB

Age

grade

Current address

Person providing information

Who does the child live with (tick all that apply)

Father's name

Father's occupation

Father's cell phone

Mother's name

Mother's occupation

Mother's cell phone

preferred email address

Alternative email address

Primary language spoken at home

Other language used at home

Please list all schools your child has attended, starting at what age and what grade

What are your child's strenghts

What are your child's weaknesses

What is the reason for this assessment. Briefly describe your concerns for your child.

Is your child

Were there any remarkable medical events noticed during the pregnancy or at birth?

How many weeks did the pregnancy last?

Child's birth weight in pounds and ounces

Describe the state of your child's current health.

Is your child currently taking medicine

List medication and uses when applicable

Has your child ever been identified as having a speech, language or learning difficulty / disability?

if so, from what age and what type of learning disability /difference

Has your child received therapy services, other additional help, tutoring or counseling

If so please describe

Has your child had any of the following? Please check all that apply

If so please describe

My child sat up

My child crawled

My child walked alone

My child Spoke first words

My child Spoke short phrases

My child Spoke short sentences

My child was fully bladder trained

My child was fully bowel trained

My child stayed dry all night

How active has your child been from an early age?

How well can your child maintain focus or concentration or pay attention to tasks?

Does your child have more difficulty than other children his/her age? Check all that apply

Does your child enjoy participating in family activities?

Does your child have difficulty getting ready for school or other activities?

Do you feel it is difficult for the child to keep track of things and stay organized?

Is your child doing any chores? (like tidying the room?)

Does your child need frequent reminder?

How would you describe your child's personality at home?

How does your child get along with siblings? if applicable

Please indicate your child's bedtime and wake time

Does your child sleep well

How much time does your child typically spend on electronic media? Please split tv, computer, game console, phone and other

How would you describe your child's peer relationships? (i.e. how many friends/is your child shy/outgoing/a leader)

How does your child feel about school?

What are her/his favorite subjects in school?

Has your child ever repeated a grade, if so which grade?

Please list your child's strengths at school

Please list your child's weaknesses at school

How motivated do you think your child is to learn?

How much time does your child spend on homework each day?

How much of a struggle is homework?

Any history of learning and attention disorders in your family?

How were the school experiences of family members, including extended family members

Does your child receive any special school services/support? (IEP, 504 plan, Gifted/Talented, special ed)

If yes please describe

Thank you for your information, please let us know anything else you feel is important for us to know.