Please list all schools you have attended, starting at what age and what grade
What is the reason for this assessment. Briefly describe your concerns
Are you currently taking medicine
List medication and uses when applicable
Have you ever been identified as having a speech, language or learning difficulty / disability?
if so, from what age and what type of learning disability /difference
Have you received therapy services, other additional help, tutoring or counseling
How were the school experiences of family members, including extended family members
Is there any history of learning and attention disorders in your family
Thank you for your information, please let us know anything else you feel is important for us to know.