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having
Your son or daughter
,,,.is
'We
plan to
difficulty in certain aieas of his/her classroom'
that we may be able
begin a screening process for your child so
be served in our
to offer suggestii*ri ut to how he/she can best
school. The screening process may include:
L. classroom strategies
2. classroom observations
.b^e x"
A-1 geL
3. vision, hearingo and health screening
4.reviewoffamilyhistoryandschoolrecords
5. review or update of psychological report
the Learning Resource
Please contact the classroom teacher or
Teacher if You have any questions'
Thank You,
/'[\,r3,
Ha*-4in
Ur*#en
Learning Resource Teacher
Please sign and return this
form to your child's classroom teacher'
REASON FOR REFERRAL
Child's Name:
Today's Date:
Date of Birth:
Child's School:
CURRENT ACADE M!C CONCERNS
What are your primary concerns about your child?
Circle areas of concern:
Language Arts: alphabet knowledge; word identification; reading comprehension; reading
fluency; weak vocabulary. Other:
Mathematics: number sense; calculations; word problems; addition; subtraction;
multiplication; division; fractions; percentages; geometry; algebra. Other:
Written Expression: poor pencil grasp; poor spacing between letters; poor letter formation;
letter reversals; spelling; capitalization; punctuation; sentence structure; grammar; paragraphs;
organization of ideas Other:
Work/Study Skills: inattention; poor concentration; overactive; restless; impulsive; slow to
process information or to respond; disorganized; initiating a new task; transitioning between
activities; poor memory or retention of new information; poor motivation
Other
Communication: poor articulation; receptive language/comprehension; expressive language;
stuttering. Other:
Comments:
^CI(r-leo-'*4+'41't-
ffi
ten
3
Disabilities
Therapy
of special education program?
Has the child ever been in any type
_Behaviorally
Emotionally Disabled
.--
lntellectual lmpairment
-Learning
-speech
Other (Please describe)
(lf yes' which grade(s)?
Has the child ever repeated a grade?
-Yes
-No
school-suspension
When?
center
from daycare
from school
Has the child ever been: _suspended
from
sctroot
-ln
-Expelled
-Expelled
tried in school? --Behavior modification
Have any of the following approaches been
report card _-Other (Please describe)
program --Qaily/weekly
RAL
NT
c
s
your child?
What are your primary concerns about
problems and what has been successful?
How have You tried to address these
reprimands (Successful:
-Yes -No)
-No)
(successful:
-Verbal of Privileges -Yes
-_Ruroval punishment (Successful: -Yes -No)
-Yes -No)
-ehyri.al
Give in to the child (Successful:
-No)
-Yes
Avoid the child (Successful:
-Yes -No)
Time Out (Successful:
'
to
your child follow directions without you having
on average, what percent of the time does
40-60%
.-?0-40%
yourself?
repeat
-q0-]l00%
--0.
-q0-80%
directions?
-o-20%
of the time does your child eventually follow
on average, what percent
20%
with respect to discipline?
-20-40% -40-60% -60-80% -80-LO0%
To what extent are you and your SpoUSe consistent
of the
time
Seldom
-Never
within the past 12 months?
Have any of the following stressful events occurred
in family
Family accident or illness
divorced or
-Most
-Some
separated
-Death
-Parents
-Parent
4
changed
jobs
(Please specify
-Changed
financial problems
moved
schools
)
-Family
-Family
-Other
From each group, circle any which apply. lndicate at what age problems first appeared:
Easily distracted
Difficulty staying seated
Often blurts out answers to questions Difficulty
Difficulty waiting turn
Difficulty sustaining attention
following instructions
Shifts from one activity to another Difficulty playing quietly
Often interruPts
Talks too much
Often loses things
Often does not listen
Often engages in physically dangerous activities
Fidgets
At what age did above problems begin?
Often
Often
Often
Often
loses
temper
requests
angry and resentful
blames others for own mistakes
refuses to follow adult
Often
Often
Often
Often
argues with adults
annoys others on purpose
spiteful or vindictive
curses
ls often touchy or easily annoyed by others
At what age did above problems begin?
Unrealistic or persistent worry about possible harm to loved ones
Unrealistic worry that a terrible event will separate the child from parent
Excessive distress when separated from home or parents
Avoidance of being alone Repeated nightmares about separation
to sleep alone Excessive physical complaints Refusal to go to school
distress in anticipation of separation from parent
At what age did above problems begin?
Refusal
Unrealistic worry about future events
Marked self-consciousness
Excessive need for reassurance
Excessive
lnability to relax
Unrealistic concern about competence
Unrealistic concern about past behavior
At
what age did above problems begin?
appetite
Depressed or irritable mood
guilt
Feelings of worthlessness or inappropriate
Feellngs of hopelessness Sleep disturbance Fatigue or loss of energy Suicidal thought
or behavior Low self-esteem can't concentrate as well as (s) he used to
Decrease or increase in
At what age did above problems begin?
M EDTCAL/DEVELOPM
E
NTAL
H
ISTORY
Know
Mother's health during pregnancy:
-Good
Mother's age when the child was born:
-Fair
-Poor
-Don't
5
Did the mother use any of the following during pregnancy?
_Never _Once
Tobacco: _Never _Once
Alcohol:
or
twice
times
Over 20 times
or
twice -3-L9
_3-19 times
Over 20 times
Medications taken during pregnancy:
Was the child born on schedule?
8 mos or
earlier
Term (8-10
mos)
_Don't
Know
Were there indications of fetal distress during labor or birth?
_No
_Yes
Don't Know
Was delivery:
_Normal _Breech
Caesarian
_Forceps _lnduced
What was the child's birth weight?
Problems with pregnancy, labor, or delivery:
Health complications following birth:
Were there any early infancy feeding problems:
Was the child colicky?
_Yes _No
_Yes _No
Were there early infancy sleep pattern difficulties?
Health problems during infancy?
_Yes _No
_Yes
No
(lf yes, please describe)
(lf yes, please
Did the child have any congenital problems (birth defects)?
describe)
-Yes
Was the child an easy baby (didn't cry a lot, followed a schedule
_Easy
_Average _Difficult
How did the baby behave with other
Average sociability
_More
people?
-No
well)?
easy
Very Difficult
-Very
_More
sociable than average
unsociable than average
6
When (s)he wanted something, how insistent was (s)he?
very insistent
insistent
_Veryinsistent _Pretty
Not at all insistent
_Very
How would you rate the activity level of the child as an infant/toddler?
-Average -Not
_Active _Average
active
At what age did (s)he walk?
-Less
-Not
At what age did (s)he speak single words (other than mama or dada)?
At what age did (s)he string two or more words together?
At what age was (s)he toilet trained?
Approximately how long did toilet training take?
or Very
How would you describe your child's current health?
_Poor
Good
-Fair
-Good
Current medical problems:
active
active
Current medications:
|ro& '*'
Qr^& -
V*o-Y'_Yes _No (lf yes, please describe) Or*"%
(lf yes, please describe)
Dr*rda *i E *'
Vision problems: Yes
(lf yes, please describe)
Problems with coordination:
-No
(lf
yes,
please
problems:
describe)
Speech
_Yes -Yes -No
lf yes, please describe
Has (s)he had any chronic health problems?
-No
-Yes -No
Hearing problems:
pox
Which of the following illnesses has the child had?
-Mumps -Chicken
_Lead poisoning _Seizures
-Measles-Whoopingcough -Pneumonia -Encephalitis -Repeated
bones _Severe
Has the child had any accidents resulting in the following?
Ear
lnfections
_Sutu
pumped
injury
Lacerations
res
-Head
-Stomach
injury
Lost teeth
-Broken
-Eye
Please list any surgeries and indicate when they were performed
7
Do you suspect that the child uses alcohol or drugs?
_No
_Yes
(lf yes, please
describe)
(lf yes, please describe)
Does the child have any history of abuse?
-No
-Yes
Does the child have any sleeping problems
No
Yes
(lf yes, please describe)
lf yes,
lf yes, how often?
(How lo
has (s)he ever been dry for some period of time?
Does the child wet the bed:
-Yes
-No
Doesthechildhaveabladdercontrol
often? _)
-No
_Yes
(lf yes,how
problemduringtheday?
-Yes -No
Yes
Does the child have bowel control problems at night or during the day?
yes, please describe)
(lf
-No
Please describe the child's appetite:
-Overeats -Average -Undereats
TREATMENT HISTORY
Medicine for
Has the child ever been prescribed any of the following?
type?
medication
_
Other medication for
-
emotions/behavior
_
ADD/ADH D (what
Antidepressant
Please list
Please list past history of psychological treatment (counseling, hospitalization, etc)
Please
SOCIAL HISTORY
describe child's relationship with brother(s)/sister(s)/mother/father:
How easily does the child make friends?
_Worse
_Easier
than average
than average
-Average
8
6-12 mos
than 6 mos
About how long does your child keep friendships?
year
_More than 1
-Less
Please describe concerns about your child's social relationships:
FAMILY HISTORY
The child's parents are:
_Married
_Divorced
(For how long
(Since
Never married
The child resides
_Mother
-)
only
_Both parents
Stepfather
with:
and
and
-Mother
-Father
specify)
only
Stepmother
(Please
-Father
-Other
Father's occupation:
Mother's occupation:
Stepfather's occupation (lf applica ble)
Stepmother's occupation (lf applicable)
The current marital situation is:
_stable
_Unstable
(lf unstable, please describe)
Has the mother ever been diagnosed with any psychological or psychiatric disorder?
No lf yes, please specify:
_Yes
J_
Has the father ever been diagnosed
J_
No
with any psychological or psychiatric disorder?
Yes
lf yes, please specify:
Mother's level of
education:
Father's level of education:
Did mother have any learning problems in school?
Did mother receive any special education services?
type?-)
ls
_
_Yes J_No
_Yes J-No
(lf yes, please describe)
(lf yes, what
there any family history of Attention Deficit Hyperactivity Disorder on mother's side?
_Yes J_No
Did father have any learning problems in school?
_Yes J_No
(lf yes, please describe)
9
J-No
Did father receive any special education services?
type?-)
ls
(lf yes, what
-Yes
there any family history of Attention Deficit Hyperactivity Disorder on father's side?
J-No
-Yes
Sibling's names
Sex Age
Grade
Are any of the child's siblings diagnosed with Attention Deficit Hyperactivity Disorder?
_J-
No
-Yes
Do any of the siblings have any other learning or psychological problems?
lf yes, please describe:
-
Yes
/-
No
Please use this space for comments:
Signature
Relationship to child
Date
10
Learning Resource Center Enrollment
Parental Consent Form
Upon careful consideration of all pertinent information regarding my
child_,
it
is my desire
to have
laced in the
Learning Resource Center to work on the areas of concern stated in the
Diagnostic/Psychologica I Report.
I understand
that there is a cost for the program, and agree to make arrangements for payment
with the school's business office.
While my child is enrolled in the Learning Resource Center program, the school is to keep me
informed of my child's academic progress. Parent Conferences will be scheduled as needed and
may involve the Educational Consultant, all teachers involved with my child, and the principal, if
necessary. Consultation will be made atthe end of the academicyearto determine continued
enrollment of my child and to make appropriate recommendations for the following year.
that should it be necessary for me to discontinue the Learning Resource Center
before it is recommended by the Learning Resource Teacher, that I may do so at any time.
understand that I am obligated to fulfill my financial responsibilities for services rendered up to
the day the programming was discontinued. I also understand that extra help being given in
the classroom, due to the recommendations provided by programming, will no longer be
available to my child upon discontinuance of the program.
I understand
I
Parent Signature
Date
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ALLABOIT MY CHILD
Dear Parents,
so that I can
better meet his or her individual needs. Please lake a
I would like to know more about your child
moment to complete this get-to-know-you letter
and return it to me by
Thank you,
Child's Name:-___
Parent's Names:___
Phone
I'mqil.
1.
What motivates your child?
2.
What kinds of things upset your child?
3. List five words
that best desoribe your child's character and./or
4.
My child's areas of strength
5.
My child struggles with:
personality_
are:
6. How would you rate your child's
attitude toward school?
1 2 3 4
7. How would you rate your child's
sense of responsibilty?
1 2 3 4
8.
Are there any personal or medical problems of which I should be aware?
9.
Do you have any additional comments or concerns?
5
5
Thank you for completing this form. I know that together we can help your child be sucoessful.
(Parent's signature)
(Date)