Child's Name
First Name
Last Name
Date of Birth
Grade
School
Parent 1 Name
First Name
Last Name
Email
Phone
(###)
###
####
Address
Parent 2 Name
First Name
Last Name
Email
Phone
(###)
###
####
Address
Child's Significant Health Information
Medications (name, dosage, time of day)
Has your child ever been evaluated by a professional? Was this at school or by an outside professional?
Does your child currently have an IEP or a 504 Plan?
Has your child ever received any additional services at home or at school? If so, please describe:
(e.g. Occupational Therapy, Speech Therapy, Physical Therapy, Counseling, etc.)
Describe your child's strengths and interests:
What is she good at? What does she enjoy doing? (at home, school, or in the community)
Describe your child's weaknesses and your concerns as a parent:
Choose up to three words that best describe your child's temperament (personality):
Describe any recent changes or stresses the child has been exposed to:
(e.g. death, relocation, divorce, remarriage, violence, health issues, etc.)
How does your child respond/interact with you as the parent?
(e.g. follow instructions [one step or multi-step], comply with directions, respond to discipline, etc.)
How does your child relate to peers?
(e.g. positive/negative interactions with siblings, friends, classmates, other family members; independent play vs. cooperative play)
What are your child's homework habits?
(e.g. completion, attention, returning work to school, organization, amount of time, ability to follow directions, independence, frustration tolerance, etc.)
Describe your child's reading ability:
(e.g. at grade level, below grade level, enjoys/dislikes reading, reads independently/with help, etc.)
Describe your child's math ability:
(e.g. at grade level, below grade level, difficulty completing homework, low test scores, etc.)
How does your child feel about school?
What does your child do after school?
(e.g. extracurricular activities, preferred activities, responsibilities, etc.)
Does your child exhibit problem behaviors at home? If so, please describe:
Describe consequences provided at home for problem behaviors:
Does your child exhibit problem behaviors at school? If so, please describe:
Describe consequences provided at school for problem behaviors:
Describe positive reinforcement (rewards) child is earns at home for positive behaviors:
Please provide any additional information: