Parent Input - Initial Evaluation
Your child has been referred for an evaluation.  Please complete this parent input form.  If you have any questions, please contact Jessica Raughley, Educational Diagnostician at jessica.raughley@cr.k12.de.us.  Thank you. 
Sign in to Google to save your progress. Learn more
Name of Child: *
Date of Completion *
MM
/
DD
/
YYYY
Person(s) completing this form & preferred title (Mr., Mrs., Ms., etc.):  *
Relationship to student:  *
What would you like to get out of this evaluation? If any, what type of support and/or accommodations do you feel your child needs? *
Medical Information
Did mother receive routine prenatal care?  If no, please explain: 
Were there any prenatal complications?  If yes, please describe: 
Did mother smoke tobacco, drink alcohol or take prescription medication during pregnancy?  If yes, how often: 
Was child born within expected gestational timeframes?  If no, please explain:
Please describe any complications at or following birth: 
Please list any other medical professional who provides ongoing or consultative treatment/services for your child: 
Notable Medical History including major medical conditions, illnesses, surgeries, allergies, current medications, etc.: 
Any sleeping obstacles? How long does your child sleep at night? 
Other relevant medical information: 
Family History
What language(s) are spoken in the home?
Is there any family history of developmental disorders?
Social Information
Please describe your child's strengths and interests: *
Please describe any activities/organizations your child is involved in:
Does your child make friends easily?  
Does your child have problems relating to or interacting with others?
Please list any significant concerns regarding your child's behavioral, emotional, or social functioning. If yes, please explain:  *
Does your child have a mental health diagnosis?  If yes, please list any relevant information (Date of diagnosis, name of diagnosing professional): 
Please provide any other supportive services (therapy, etc) your child benefits from: 
Educational Information
Please describe your child's learning needs:
Please list strategies, accommodations or specially designed instruction that you feel your child benefits from:  *
Please provide specific areas of concern you have regarding your child:  *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Caesar Rodney School District.

Does this form look suspicious? Report

Google Forms