NORTH PENN SCHOOL DISTRICT
401 East Hancock Street * Lansdale, PA 19446 * 215-368-0400 * 215-855-6926 Fax * www.northpennschools.k12.pa.us
PARENT INFORMATION FORM
EARLY INTERVENTION
Student Name:____________________________________________________Date:________________
Date of Birth:______________________________
Dear Parent or Guardian,
We would like you to complete this information form as part of the evaluation of your child. The
information will be used to help make recommendations for your child’s educational program upon
school entrance.
How would you rate your child in the following areas?
Area
The ability to understand your child’s
speech
Your child’s ability to understand
when spoken to
Your child’s ability to use language to
communicate with others
Your child’s ability to play with other
children the same age
Your child’s attention span
Your child’s ability to walk, run, and
climb stairs
Your child’s ability to do things such as
turn doorknobs, pick up objects, snap
or button
Your child’s ability to hold a pencil,
draw, and cut
Your child’s beginning reading skills
such as letter recognition and saying
the alphabet
Your child’s beginning math skills such
as counting and recognizing numbers
Poor
Satisfactory
Excellent
With which skills does your child need the most help?
_____________________________________________________________________________________
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What are your child’s strongest skills?
_____________________________________________________________________________________
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Do you have any concerns about your child’s socialization skills and/or behavior in school?
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have any concerns about your child’s speech/language or fine motor skills?
_____________________________________________________________________________________
_____________________________________________________________________________________
Does your child have a significant medical history? Please list any current medical conditions, and dates
and descriptions of any major illnesses or injuries.
_____________________________________________________________________________________
_____________________________________________________________________________________
Has your child had any previous evaluations by a psychologist, developmental pediatrician, or
neurologist? If so, please provide the dates and names/addresses of each evaluator or physician
_____________________________________________________________________________________
_____________________________________________________________________________________
Is your child currently being monitored by any medical personnel?
_____________________________________________________________________________________
Are you currently providing any therapy, such as speech, occupational therapy or physical therapy, for
your child in addition to what your child receives as part of the IEP? If so, when did you begin these
services? How often does your child receive these services?
_____________________________________________________________________________________
_____________________________________________________________________________________
Does your child receive wrap around services from a community agency at your home or at the school?
If so, what does your child currently receive?
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any medications your child is taking currently:
_____________________________________________________________________________________
What, if any, concerns do you have about your child’s educational program when your child starts
school?
_____________________________________________________________________________________
_____________________________________________________________________________________
*** Please feel free to use the remainder and back of this form to write additional comments, questions,
and/or concerns.
Parent/Guardian Signature _______________________________________________________________
Home Phone ______________________________ Work Phone _________________________________