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WelcomeWmPitcher2020-11-15T15:45:47-05:00

General Info About Child

Child's First Name *

Gender *

Boy

Girl

Child's Last Name *

School *

Birthdate *

Grade *

Enter 0 for Kindergarten or JK.

Age *

Primary Language *

Mother Tongue

Other Languages Spoken *

General Info About Child's Parents/Guardians

Parent 1 First Name *

Education

Parent 1 Last Name *

Mobile Phone *

Employer

Work Phone

Role/Occupation

Email *

Address *

City *

Province *

Postal Code

Parent 2 First Name *

Education

Parent 2 Last Name *

Mobile Phone *

Employer

Work Phone

Role/Occupation

Email *

Address *

City *

Province *

Postal Code

Name of Person Completing This Form *

Relationship to Child *

Referred By

Medical History

Date and results of last vision and hearing exams. Please indicate which of the following have been evaluated:

Visual Accuity

Date

Results

Binocular Focus, Convergence & Tracking

Date

Results

Visual Processing

Date

Results

Hearing

Date

Results

Does child have a history of ear infections? If so, please describe.

Has child been given a diagnosis at any time of Dyslexia, Dyspraxia, ADHD, CAPD or similar? If so, please describe:

Has child ever taken medication for ADD/ADHD or any other condition that may affect their learning (eg. depression, anxiety etc.) If so, please explain:

Has child ever had a head injury? When? How serious? Hospitalized?

Please list any testing or evaluations done either by school districts, colleges, psychologists, speech pathologists, educational therapists etc. (please include copies of any reports or IEPs).

Please list any psychologists, speech pathologists, educational therapists, tutors or others who have provided services for your child. Describe the nature of the therapy/tutoring and the duration.

Please describe any motor issues (eg. sitting, crawling, walking) the child has faced. Has the child fallen behind, met or exceeded developmental milestones?

Please describe any speech development issues (eg. first words, naming objects, sentences) the child has faced. Has the child fallen behind, met or exceeded developmental milestones?

Please describe any complications or special circumstances involving the child's pregnancy or birth:

Please describe child's sleeping pattern -- both weekday and weekend:

Would you say child has a healthy diet? Any strong food aversions? Any allergies? Does the child eat on a regular schedule?

School / Learning Experiences

Describe child's challenges. Why are you seeking assistance?

How does child feel about school overall?

Has child had any noteworthy school developments such as homeschooling, repeating a grade or missing an extended period of schooling? If yes, please explain:

Child's Best / Favourite Subject:

Other things child most likes about school:

Child's Most Difficult / Least Liked Subject:

Other things child most dislikes about school:

Does child have difficulty in any of the following subject areas? Check all that apply:

Speech

Reading

Writing

Spelling

Math / Arithmetic

Please describe the difficulties for any checked subject areas:

Please describe any organizational issues the child has:

How does child deal with transitions to new situations such as embarking on a new school year or trying new/unfamiliar activities?

How does child relate to peers? Does child have many friends? Does he/she prefer same age, younger or older friends? Any difficulty establishing or maintaining friendships?

Describe child's outdoor activities and other active pursuits:

Describe child's strengths and passions:

Do you have any other concerns about the child's life, school life or academic performance that have not been shared above?

Family Background

Sibling 1 Name

Brother / Sister

Brother

Sister

Date of Birth

Relevant Educational Info

Sibling 2 Name

Brother / Sister

Brother

Sister

Date of Birth

Relevant Educational Info

Sibling 3 Name

Brother / Sister

Brother

Sister

Date of Birth

Relevant Educational Info

Other Siblings and Relevant Information

Has anyone else in the family had difficulty learning or been diagnosed with a learning disability? If yes, please describe:

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Site Links

Home
Educational Therapy
Programs
Success Stories
About
Contact Adele

Contact us

Adele Sherman
Toronto, Ontario, Canada

Phone: 416-995-8757

Email:

Web: https://learnability.ca