CHILD INFORMATION: |
| Child’s First Name * |
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Child’s Last Name * |
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| Preferred Name |
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Date of Birth * |
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| Child’s Gender |
Male
Female |
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YOUR INFORMATION (person filling out this form) : |
| Your First Name * |
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Your Last Name * |
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| Relationship to Child |
Mother
Father
Others |
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PARENT CONTACT INFORMATION: |
| Home Address * |
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| Home Phone |
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| Mother’s Mobile Phone |
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Mother’s Work Phone |
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| Father’s Mobile Phone |
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Father’s Work Phone |
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| E-mail Address |
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Mother
Father |
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| Preferred Daytime Phone |
Home
Mother's Work
Mother's Mobile |
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Father's Work
Father's Mobile |
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| SCHOOL INFORMATION |
| School Name and Location: |
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| School Class: |
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School Type:
Regular
Special Education |
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| REFERRAL CONCERNS
(Please check all that apply) |
| Reading: |
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Reading decoding (sounding out/reading individual words) |
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Reading comprehension (understanding concepts, reasoning with text) |
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Reading speed (reading rate/fluency) |
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Vocabulary (learning and remembering new words) |
| Math: |
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Recalling math facts (e.g. times tables) |
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Remembering math procedures (e.g. steps necessary to solve problems) |
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Understanding math concepts (general comprehension, logic, reasoning with math) |
| Writing: |
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Written expression (quality of ideas, effectiveness of communication) |
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Spelling |
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Mechanics of writing (punctuation, grammar) |
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Handwriting (legibility and efficiency) |
| Foreign Language : |
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Comprehending when listening |
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Vocabulary (learning and recalling new words) |
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Spelling, grammar |
| Speech : |
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Difficulty with enunciation |
| Hearing : |
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Hearing |
| Attention and Executive Control : |
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Attentiveness in classroom (e.g., maintaining focus, not getting distracted) |
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Productivity in classroom (e.g. managing time effectively, planning work) |
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Getting homework completed and turned in on time |
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Self-corrections of output (e.g. checking work, catching mistakes) |
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Keeping materials organized (e.g. textbooks, assignments, backpack tidiness) |
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Impulsivity (e.g. speaking out of turn, acting before thinking) |
| Memory : |
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Remembering information, in general |
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Remembering isolated facts (e.g. dates, names studied for exams) |
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Remembering correct sequence or order (e.g. months of year in order) |
| Other : |
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Motivation |
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Self-esteem |
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Getting along with others |
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Gross motor coordination (e.g. sports, catching a ball, balance) |
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Fine motor coordination (e.g. writing, cutting with scissors, sewing) |
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Working quickly enough, in general |
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Communicating orally |
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| PREVIOUS ASSESSMENT DETAILS |
| Has your child been assessed previously for school learning problems?
Yes
No |
| When was the most recent assessment completed? |
Month
Year
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Where was the most recent assessment completed?
(e.g. school, clinic) |
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Who completed the most recent assessment?
(e.g. psychologist, teacher) |
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If the most recent assessment resulted in a label or diagnosis, please select all that apply from list below: |
Reading Disability
Writing Disability
Math Disability
Speech Language Delay
Mental Retardation
Pervasive Developmental Delay
Autism
Asperger’s Syndrome
Attention Deficit Disorder |
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Other (Give details) |
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| Does your child currently receive special education services? (e.g. school pull-out for extra help, private clinician or at-home tutoring)
Yes
No |
| If yes, please describe the types and frequency of services: |
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OTHER CONCERNS |
Has your child exhibited any significant emotional or behavioral issues at home or at school?
Yes
No |
If yes, are your child’s emotional or behavioral issues the primary reason you are seeking a consultation at Learning Matters?
Yes
No |
| If you have concerns about your student’s emotional or behavioral difficulties, please briefly describe them, as well as how they are being addressed (e.g., counseling): |
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ADDITIONAL INFORMATION |
| Please provide any additional information you believe would be helpful for us to know regarding your child: |
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