Application request for psychoeducational assessment
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Child's Name: *
Child's Date of Birth: *
Name of School: *
Child's father's name:
Child's mother's name:
Family address: *
Father's cell phone number, employer name and job title:
Mother's cell phone number, employer name and job title:
Father's e-mail address:
Mother's e-mail address:
Reason for request for psychoeducational testing: *
Sibling names, ages and school attended: *
Please identify any medical and/or developmental (which includes physical, cognitive, language, emotional, or social) concerns in the child's first two or three years of life. *
Developmental milestones: At what age did your child first.... *
under 1 years old
1 years old
2 years old
3 years old
4 years old
Sit Unassisted
Say Single Words
Crawl Unassisted
Walk Unassisted
Become Toilet Trained
Please list the contact information of any professionals or resources previously or presently involved in your child's care: *
Has your child been tested for hearing loss?: *
Has your child ever had a seizure? *
Is your child on any type of medication? *
Has your child been tested for vision impairment? *
What is the name of your child's main (home room) teacher and how is this teacher best contacted? *
What are your hopes and goals for your child in the short/long term? *
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