Teacher Information Form
Dear Educator, your student is being evaluated by Dr. Rosen. Please complete the following form about your student's academic and social performance to help in our assessment and treatment. Feel free to contact Dr. Rosen at 212-235-7130 for any questions or concerns.
Email address *
Teacher's Name: *
Teacher phone or email: We would like to be in touch. Please let us know what hours we should call or if you prefer email?
Name of student: *
Name of school:
Grade:
Type of classroom setting (ie: general ed, special ed--please specify)
Does child have an IEP? If so, please explain classification and services provided
Academic Performance
What are the child's academic strengths?
What are the child's academic difficulties?
Has the child's performance noticeably improved or declined recently?
Is there any suspicion for learning disabilities? Please explain:
Behavior
How would you characterize the child's behavior (ex: disruptive, restless, compliant, shy, fearful, withdrawn, serious, inattentive etc)?
How does the child relate to other children? Any concerns for bullying or difficulty with making friendships?
How does the child relate to authority figures?
Do you have any concerns about the child's academic or behavior performance? Please explain:
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