Please complete this form before your child's scheduled assessment.

Student

First Name

Last Name

Current Grade

School

Parent 1

First Name

Last Name

Parent 1 Cell

(###)

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Parent 2

First Name

Last Name

Parent 2 Cell

(###)

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Home Address

Home Phone

(###)

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Email address (for statements and announcements)

Medical Conditions/Allergies

Dietary Restrictions

Emergency Contact 1

First Name

Last Name

Emergency Contact 1 Phone

(###)

###

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Emergency Contact 2

First Name

Last Name

Emergency Contact 2 Phone

(###)

###

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Emergency Contact 3

First Name

Last Name

Emergency Contact 3 Phone

(###)

###

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Section A

What is your greatest concern regarding your child's academic skills?

What are your goals with respect to your child's academic skills?

What are his/her greatest strengths/weaknesses academically?

When did your child begin to read?

Does your child attempt to read on his/her own? Does your child ask you to read to him/her?

Does your child engage in regular temper tantrums or outburst at home or at school? If yes, please explain.

What is homework time like?

Does your child seem anxious or nervous in his/her school environment? How is his/her confidence with respect to school? Socially? In general?

Does your child have any other behavioral issues?

Does your child have any medical problems?

What previous treatments have you attempted for learning and/or behavior problems?

Does your child have a diagnosis? What was the age of diagnosis? Who provided the diagnosis?

Section B

If your child is diagnosed with a learning disability or has an IEP, please answer all questions in Section B.

Does your child meet developmental milestones normally? Speech milestones? Fine/gross motor milestones?

Did your child have any language delays?

Does your child engage in stereotypical behaviors?

Does your child have any sleeping problems?

Does your child qualify for any special education services?

Does your child have an IEP? If so, do you feel as if the IEP goals have been met?

What are your concerns with your child's current educational placement?

Intake Form