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Name of Student
Parents Name(s)
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Phone
Email
Student Age
Student Grade Level
Student's Birthday
School
Public or Private School
Public
Private
Has your student ever been tested by the school or another professional? If so, please describe:
Date of testing
What was the recommendation or diagnosis?
Does student have an IQ score? If so, what is it:
Was your student ever retained?
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If so, what grade?
Do you have an IEP?
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If so, what category?
Do you have a 504?
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If so, what category?
When were you first aware of academic struggles?
Has your student had any other outside tutoring or therapy? Please describe:
Has anyone suggested your student might have ADD or ADHD?
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Is your child currently taking medication for ADD/ADHD?
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If yes, will your student be on their medication during their screening?
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Do any relatives have the classic warning signs of dyslexia?
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Has your student had a recent hearing and/or vision exam in the past 18 months?
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If yes, what were their results?
Did you experience any problems or issues during pregnancy?
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If yes, please explain:
Is your student adopted?
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If yes, from what country and at what age?
Is English your student's first language?
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Any history of seizures or brain damage/injury?
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If yes, please explain:
Does your student have trouble with balance or coordination?
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Does your student have trouble maintaining eye contact?
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How would you describe your student’s social skills?
How would you describe your student’s outlook on life and learning?
How would you describe your student’s attitude toward school?
How does your student respond to academic frustration?
Does your student have a history of challenging behavior, defiance, or physical aggression?
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If yes, please explain:
Are there any issues related to parental custody or permission for services that we need to be aware of?
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If yes, please explain:
Which of the following have you observed in your student? Please check all that apply:
Delayed speech - not speaking after 12 months
Mixing up sounds or syllables when saying long words (spaghetti/pasghetti, animal/aminal)
Articulation Difficulties (r-l, m-n, s-sh-ch, th-f) – may have worked with a speech therapist
Early stuttering
Chronic ear infections
Constant confusion of left vs. right
Late to establish a dominant hand
Difficulty learning to tie shoes
Trouble memorizing address, phone number, or the alphabet
Early trouble creating rhyming words
Poor or illegible handwriting
Laborious or effortful handwriting
Letter or number reversals continuing past the end of first grade
Holds pencil with an awkward grip
Finds handwriting fatiguing
Difficulty drawing basic figures (shapes, common objects, etc.)
Dreads going to school – may complain of illness
Difficulty with word retrieval when speaking
Extremely poor written expression as compared to oral expression
Which of the following math-related difficulties have you observed in your student? Please check all that apply:
Cannot remember math facts
Cannot remember sequences of steps
Difficulty learning new math concepts
Frequent confusion/substitution of mathematical symbols or functions
Trouble with directionality
Difficulty keeping problems organized
Difficulty telling time on a clock with hands
Misaligns problems when writing on paper
Relatd to difficulty copying off the board accrately, which of the following have you observed? Please check all that appy:
Can only copy one or two letters at a time
Often loses place when copying
Makes mistakes or skips words when copying
Relatd to near-point copying, which of the following have you observed? Please check all that appy:
Can only copy one or two letters at a time
Often loses place when copying
Makes mistakes or skips words when copying
Difficulty taking notes during lectures
Extreme difficulty learning a foreign language
Difficulty reading printed music
Homework takes an excessive amount of time or cannot be completed without assistance
Low self-esteem
Are there any concerns you have that were not mentioned above? If so, please describe:
How did you hear about Learning for All?
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