Father's cell phone number, employer name and job title:
Your answer
Mother's cell phone number, employer name and job title:
Your answer
Father's e-mail address:
Your answer
Mother's e-mail address:
Your answer
Reason for request for psychoeducational testing: *
Your answer
Sibling names, ages and school attended: *
Your answer
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. *
Your answer
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
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: *
Your answer
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? *
Your answer
What are your hopes and goals for your child in the short/long term? *