Your full name

DOB

Age

grade or last highest education

Current address

preferred email address

Alternative email address

Primary language spoken at home

Other language used at home

Please list all schools you have attended, starting at what age and what grade

What are your strengths

What are your weaknesses

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

Describe the current state of your health

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

If so please describe

Have you had any of the following? Please check all that apply

If so please describe

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