CONDITION REPORT: Emotional Disturbance
Yes
No
At the present time, the characteristics that Xxx exhibits are of sufficient severity,
intensity, and/or duration to meet criteria for the condition of emotional disturbance.
Specifically, Xxx exhibits one or more of the following characteristics over a long
period of time and to a marked degree: (check only those criteria that are met; give an
explanation under each of why the student does or does not meet it)
(1) an inability to learn which cannot be explained by intellectual, sensory, or health
factors: (explain)
(2) an inability to build or maintain satisfactory interpersonal relationships with peers and
teachers: (explain)
(3) inappropriate types of behavior or feelings under normal circumstances: (explain)
(4) a general pervasive mood of unhappiness or depression: (explain)
(5) a tendency to develop physical symptoms or fears associated with personal or school
related problems: (explain)
Yes
No
The emotional disturbance adversely affects the student’s educational performance.
By reason of the emotional disturbance, the student needs special education and
related services.
(If no, explain)