AREAS ADDRESSED:

Early Intervention

Fine and Gross Motor Skills

Literacy (Reading, Spelling, Phonics, and Written Expression)

Sensory Integration / Processing Dysfunction (Visual and Auditory)

Attention Issues (ADHD / ADD)

Organization and Study Skills

Problem Solving

Comprehension

Working Memory and Long-term Memory

Reasoning and Logic

Processing and Perceptual Therapy, Consultation and Early Childhood

Questionnaire

Visitor IP: 216.73.216.51

Student Information

Full Name
Home Address
(optional 2nd line)
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Date of Birth	January February March April May June July August September October November December 12345678910111213141516171819202122232425262728293031 2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970
Gender	Male    Female

Parent Information

Name of parent or guardian
Home Address
(optional 2nd line)
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Home Telephone

Academic Information

Current grade	K 123456789101112
Present school
Previous schools child has attended

Developmental Information

Professional who most recently evaluated the student:
Name
Title
Address
(optional 2nd line)
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Estimated developmental age	123456789101112131415161718
Has the student ever received assistive / remedial services?
If yes, please indicate:	Early intervention / special education Occupational Therapy Physical Therapy Speech/Language Therapy Tutoring
What areas were addressed?