18 and Under Intake and Screening

Intake and Screening
Address
Address
City
State/Province
Zip/Postal
Is there a history of learning difficulties in the family?
Is this child enrolled in school?
Has the child repeated a grade?
Does the child receive extra help in reading at school?

How Would You Rate Your Child's...

School Grades
School Attendance
School Attitude
School Conduct

Reading

Is your child experiencing reading difficulty?
Does your child reverse letters?

Writing and Spelling

Does your child experience problems writing?
Is your child's writing legible?
Does your child reverse letters when writing?
Can your child write in both print and cursive?
Does your child have problems spelling?

Speech

Does your child have speech problems?
Has your child ever received speech or language services?
Does your child have hearing problems?
Does your child have vision problems?
Which hand does your child prefer to write with?

Health

Does your child have any allergies?
Has your child been diagnosed with ADD or ADHD?
Are there any medical conditions we should be aware of?
Has your child had any psychological or psychiatric evaluations?
Has your child ever had lead poisoning?
Is the child on any medications?