Please check this box if you are a parent filling out this form on behalf of your child:

Yes, I am a parent filling out this form on behalf of my child.

Examinee's name:(Required) *

First

Examinee's name

Last

Today's Date(Required) *

Birth date:(Required) *

Grade (if applicable):

Contact Information:

Parent Name(s) (if applicable):(Required) *

Address *

Street Address

Address Line 2

State

ZIP / Postal Code

Best Telephone Contact Number:(Required) *

Residents in examinee's home:(Required)

Enter Your Name and 'Self' if completing for self. Click the + icon to add more.

First Name *

Last Name *

Relationship to Examinee *

Language(s) spoken in the home:(Required) *

Institution/School:(Required) *

Background Information:

What have you tried to do in the past to support the question(s)/concern(s)?(Required) *

What are the concerns or questions you would like addressed by this evaluation?(Required) *

Has this examinee already had testing/evaluations/IEP?(Required) *

Yes

Who did the testing?(Required) *

What were the results and conclusions?(Required) *

Medical Care

Examinee's physician:(Required) *

Telephone:(Required) *

Date of last visit:(Required) *

Has the examinee ever had psychological counseling or therapy?(Required) *

Yes

Counselor's name:(Required) *

Telephone *

Type of counseling:(Required) *

End date:(Required) *

Start date:(Required) *

Has the examinee ever had a neurological exam?(Required) *

Yes

Neurologist's name:(Required) *

Date of exam:(Required) *

Reason for exam:(Required) *

Has the examinee ever had a psychological or psychiatric exam?(Required) *

Yes

Counselor's name *

Date of exam: *

Reason for exam: *

Educational History

Did the examinee attend preschool?(Required) *

Yes

Was the examinee ever retained?(Required) *

Yes

When?(Required) *

List all the schools the examinee has attended:(Required)

(for "special help" - please enter "No" if none was required)

Name of School: *

Grades: *

Special Help? Type of Help? *

Is/was the examinee absent from school frequently?(Required) *

Yes

If yes, why?(Required) *

Are/were there any concerns about the quality of the examinee's school or teachers?(Required) *

Yes

Describe:(Required) *

Family History

Is the examinee closer to one parent than the other?(Required) *

Yes

Which?(Required) *

Has the examinee ever experienced any parental separations, divorces or death?(Required) *

Yes

When? *

How old was the examinee at the time?(Required) *

Please describe the circumstances:(Required) *

If the examinee is a minor and the parents are separated or divorced, who has custody of this minor?(Required) *

How often does the other parent see this minor?(Required) *

Who administers the educational rights of this minor?(Required) *

Brothers/Sisters

Please list all brothers and sisters, and any other individuals living with the examinee.

Age

Sex

Relationship to the examinee

Living at home?

How does the examinee get along with others living in the same household?(Required) *

What are the examinee's strengths?(Required) *

What are the examinee's areas for growth?(Required) *

What is the examinee's level of education?(Required) *

high school

technical or vocational school

college

law, medical, advanced studies

Friendships

Has the examinee had problems relating to others?(Required) *

Yes

Please describe:(Required) *

Recreation/Interests

What activities does the examinee enjoy?

Sports?(Required) *

Hobbies?(Required) *

Other:

Contact Information:

Residents in examinee's home:(Required)

Enter Your Name and 'Self' if completing for self. Click the + icon to add more.

Background Information:

Prenatal History

Birth History

Number of days in the hospital for birth:(Required)

Developmental History

When did the examinee first:

Current Health