Your Initials *

Your Name *

Your Email *

Your Phone *

Child's Name *

Child's Date of Birth *

Reason for requesting an assessment *

Has your child had a previous psychological or educational evaluation? If yes, please describe in detail including type of evaluation and resulting diagnosis. *

Has your child been to the doctor in the past year? If so, how is the child’s current health? Is he/she being treated for anything? *

Has your child had both hearing and vision screenings in the past year? Please describe: *

Please describe any medical or physical problems your child has had: *

Is your child currently taking medication, either prescription or over the counter? If yes, carefully list the specific medication and dose date first prescribed, who prescribed, and for what purpose: *

Please list any medications your child has taken in the past, and the reason for the prescriptions: *

Were there any problems or unusual circumstances during pregnancy or delivery? If yes, please describe: *

Was the child adopted? (please choose) (please choose) *

Were there any developmental problems including delay in learning to crawl, walk, or talk? If yes, please describe: *

Please describe your child's current living situation (i.e. both biological parents and a younger brother) *

Please provide a comprehensive school history, including name/type of schools attended and current school/grade level: *

Please describe any of the following problems your child has experienced, including the time of onset for each:

Reading difficulty, writing difficulty, mathematics difficulty, poor grades, homework problems, peer problems, and/or organizational problems: *

Please describe your child’s greatest strengths and any special abilities or talents. What school subjects have he or she generally done best in? *

What problems, if any, does your child have with fears, tension, anxiety, panic attacks, phobias, being uncomfortable in new situations, or shyness? How has this changed over time? *

What problems, if any, does your child have with self-esteem? Are there particular things your child is most likely to feel bad about? *

Does your child have any problems with sleep? If yes, please describe: *

Please identify any blood relatives (i.e. “Dad’s brother”) who have or had learning or psychological difficulties of any kind: *

Is there anything else it would be helpful to know about?