1.  List name of student, age, date of birth.

2.  Family. List immediate family members living in/out the home currently. List siblings and ages. List parents’ names. If separated or divorced list dates and if applicable names of stepparents, step-siblings or half-siblings, cities/states of residence as well. Describe frequency and duration of visitation.

3.  Contact information. Please list current mailing address, preferred email for parent/s, email of student (if applicable), phone number, mobile number of parents and student (if applicable).

4.  Addresses. List all cities/towns student has lived and dates of residence.

5.  Native tongue. English speaking home? Dual language home?

6.  Developmental history. Expressive language (e.g. utterances, words, sentences) on time, earlier or later? Physical milestones (e.g. standing, crawling, or walking) on time, earlier, or later?

7.  Vision and hearing. Typical? Explain?

8.  Hobbies student is interested? How student spends time after school? Summer?

9.  List all school placements beginning in preschool through current. Dates included.

10.  Any previous learning disabilities or attention deficit disorder previously diagnosed?  If yes,  diagnosis/es?  By whom?  Year?

11.  List of all medical doctors, cities/states, and description of any childhood illnesses, injuries or hospitalizations, any diagnosis/dates if applicable.

12.  List of all medications prescribed in past/current and dates.

13.  List of all speech and language, occupational, vision and psychological therapy: names of providers and dates of service.

14.  Any documented or suspected history in the family of learning disorders, anxiety or mood disorders, or attention deficits. If so, what is the relationship to the student?

15.  If applicable list job history (employer, position, dates of employment)

16. History of tutoring? Subjects, tutor name/agency, dates.

17. Illnesses, hospitalizations, injuries?

18. Pottytraining. Early typical late? Bedwetting? Explain.

19. Eating. Typical? Picky? Colic as baby? Eating disorders? Overweight?

20.  Sleeping. Easy typical difficult falling asleep and waking? Explain. Hours each night of sleep.

21.  Goal of this evaluation.

22. Any other concerns or considerations that would be helpful for the examiner to know and understand.

23.  Referral source:  Contact person, organization, website or other.

On the day of the testing appointment:

1.  Please bring lunch, snacks and beverages for the student. 

2.  Bring recent school records including report cards, and 504Plan/IEPs if applicable, standardized testing results (e.g. SOL, State/County achievement testing, PSAT, ACT). This examiner would prefer comprehensive file dating as far back as possible. All records will be returned.