Person providing information
Who does the child live with (tick all that apply)
Please list all schools your child has attended, starting at what age and what grade
What is the reason for this assessment. Briefly describe your concerns for your child.
Were there any remarkable medical events noticed during the pregnancy or at birth?
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
Does your child have more difficulty than other children his/her age? Check all that apply
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)
Please list your child's strengths at school
Please list your child's weaknesses at school
Does your child receive any special school services/support? (IEP, 504 plan, Gifted/Talented, special ed)
Thank you for your information, please let us know anything else you feel is important for us to know.